Management Of Discogenic Back Pain Research Articles

Ultrasound Guided Erector Spinae Plane Block with Ozone & Corticosteroid for the Management of Discogenic Back Pain: A Case Report

Lumbar fluoroscopic or CT-guided intra-discal ozone injections with or without corticosteroid, have reportedly been a successful back pain-sciatica treatment. Ozone may also enhance the longevity of corticosteroid anti-inflammatory effects. However, growing evidence that the mere act of needle puncturing the intervertebral disc may inadvertently set off an annular degenerative cascade taking several years to manifest, has prompted a search for less invasive yet effective alternatives. Ultrasound Guided (USG) Erector spinae plane (ESPB) blocks may offer a relatively safer, less technically challenging alternative to intra-discal ozone injection by means of diffusing ozone through tissues into the gas-permeable annulus, rather than injecting ozone into the disc itself. ESPB is a relatively new procedure and its use with ozone in DLBP management has not yet been described in the literature. This paper details the management of a 40-year-old male chef suffering from disabling low back pain and unilateral lower limb radiculopathy using an ESBP with Ozone-corticosteroid, with rapid-sustained pain relief, and restoration of sustained work-ADL function on 6 months follow up.

In silico feasibility assessment of extracorporeal delivery of low-intensity pulsed ultrasound to intervertebral discs within the lumbar spine

Low intensity pulsed ultrasound (LIPUS) may have utility for non-invasive treatment of discogenic lower back pain through stimulating, remodeling and accelerating healing of injured or degenerated intervertebral disc (IVD) tissues. This study investigates the feasibility of delivering LIPUS to lumbar IVDs between L2 and S1 spine vertebra using a planar extracorporeal phased array (8 × 8 cm, 1024 elements, 500 kHz). Three 3D anatomical models with heterogenous tissues were generated from patient CT image sets and used in the simulation-based analysis. Time-reversal acoustic modeling techniques were applied to optimize posterior-lateral placement of the array with respect to the body to facilitate energy deposition in discrete target regions spanning the annulus fibrosus and central nucleus of each IVD. Forward acoustic and biothermal simulations were performed with time-reversal optimized array placements and driving amplitude/phase settings to predict LIPUS intensity distributions at target sites and to investigate off-target energy deposition and heating potential. Simulation results demonstrate focal intensity gain of 5–168 across all IVD targets and anatomical models, with greater average intensity gain (>50) and energy localization in posterior, posterolateral, and lateral target sites of IVDs. Localized LIPUS delivery was enhanced in thinner patient anatomies and in the high lumbar levels (L2-L3 and L3-L4). Multiple amplitude/phasing illumination patterns could be sequenced at a fixed array position for larger regional energy coverage in the IVD. Biothermal simulations demonstrated that LIPUS-appropriate exposures of 100 mW cm−2 ISPTA to the target disc region would result in <1 °C global peak temperature elevation for all cases. Hence, simulations suggest that spatially-precise extracorporeal delivery of therapeutically relevant LIPUS doses to discrete regions of lumbar IVDs is feasible and may be useful in clinical management of discogenic back pain.

Degenerate-disc infection study with contaminant control (DISC): a multicenter prospective case-control trial

BACKGROUNDA bacterial cause of disc degeneration has evoked several controversies and, if true, would lead to a major shift in treatment paradigm. Earlier studies analyzing the relationship of bacterial disc infection within a degenerative cohort featured prolonged cultures susceptible to contamination. The degenerate-disc infection study with contaminant control (DISC) trial aims to investigate this theory further by examining infection rates using a non-degenerative control cohort in comparison to a degenerative internal control cohort and a sham cohort (sampling only sterile paraspinal tissue). To our knowledge, the current study is the largest evaluating the growth of organisms (or possible contamination rate) in paraspinal tissue if prolonged cultures are performed. Protocols on methodology have been previously published. PURPOSE(1) To investigate the infection rates across cohorts (degenerative vs. nondegenerative control; paraspinal and/or disc controls vs. combined sampling cohorts) using stringent standardized aseptic surgical technique and laboratory processing. (2) To compare our findings to that of the literature and make a statement in support and/or against a possible contamination theory to positive cultures. STUDY DESIGNMulticenter, multisurgeon case-control trial. PATIENT SAMPLEIn all, 812 surgical samples were retrieved across a 3.5-year period (2013–2016) including 25 trauma controls (nondegenerative), 550 "disc and paraspinal” samples (degenerative cases with internal control), 190 disc-only samples (degenerative cases without internal control), and 46 paraspinal only controls (sham group). OUTCOME MEASURESGrowth and/or Contamination rate (%) per cohort. Chi-square of growth in disc versus paraspinal samples as a means of examining the distribution of false positive and contaminant growth. The impact of previous injections and/or surgery on positive disc or paraspinal growth. Correlation of Modic changes with positive growth rates analyzed with the Kruskal-Wallis Test. The distribution of species in positive samples were also analyzed. METHODSThe DISC trial is registered under Australian and New Zealand clinical trials registry—ACTRN12616000541404. Institutional ethics review was obtained (HREC northern sector 13/218) at the primary center and further centers (n=6) were recruited. Patients undergoing spinal surgery with discectomy were eligible for trial entry with tissue specimens obtained using strict aseptic technique for microbiological examination. All specimens were handled with sterile instruments only and by a fresh instrument to a sterile pot that was closed immediately. Separate pots were used for the disc and paraspinal tissue respectively with similar stringent processing during microbiological assessment. A cohort of the degenerative cases at one single institution also underwent an additional histopathological examination. RESULTSThere was an expected significant difference in gender and age associated with the non-degenerative control group (due to trauma patients) compared with other cohorts. There was a higher percentage of positive-growth in the control group in comparison to the disc and paraspinal and disc only groups across positive disc growth (48% vs. 27% vs. 17%, p<.001). A similar infection rate was observed in the paraspinal samples across the equivalent controls (44% vs. 36% vs. 37%, p=.739). There was a significant difference in the proportions of positive growth with a large proportion of false positives (growth in both disc and paraspinal samples; p<.001). There was no difference in true positive growth between the case and control groups (16.0 vs. 7.7%, p=.112). These trends were preserved across all cohorts and when stratifying by spinal segment (cervical or lumbar). There was no correlation between Modic changes and positive disc culture growth (p=.398, n=144 samples). Cutibacterium (formerly Propionibacterium) acnes was the most dominant pathogen isolated, representing between 50% and 70% of positive disc and paraspinal specimens, followed by staphylococcal species. CONCLUSIONSOur study failed to find a difference in true infection rates between the nondegenerative and degenerative disc populations. These findings are suggestive of a contamination theory and against a common infective etiology in the setting of discogenic back and neck pain. We believe the rationale for antibiotic therapy in the management of discogenic back pain warrants further evidence to establish efficacy.

Rami communicans fibers in discogenic low back pain: The controversies

Intervertebral disc innervation and mechanism of discogenic low back pain is a subject of debate. There is no controversy regarding innervation of anterior and lateral annuli. Nociception from this part is carried by sympathetic pathway. Sinuvertebral nerves innervate posterior annulus, but there are controversies about nociceptive pathway from posterior annulus. It can be mixed somatic and sympathetic or can be completely sympathetic pathway through rami communicans fibers. Local anesthetic block of rami communicans fibers with or without steroid gives very good results in discogenic low back pain. But radio frequency ablation of rami communicans fibers do not give consistent result. This article has tried to find the literature about disc innervation, role of rami communicans nerves in transmission of discogenic back pain, and role of rami communicans nerve block in management of discogenic back pain.

Non-operative management of Discogenic Back Pain by Intradiscal Interventions: an evidence based review

Non-operative management of Discogenic Back Pain by Intradiscal Interventions: an evidence based review

Nonoperative management of discogenic back pain: a systematic review.

Systematic review of the literature. A systematic evaluation of the literature was performed to investigate current nonoperative management of the treatment of discogenic low back pain. Back pain is a major health care concern with up to 39% being discogenic in origin according to one study. Nonoperative therapy is likely to be the initial treatment strategy for discogenic low back pain. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for clinical studies evaluating nonoperative methods of treating discogenic back pain that were published between 2000 and 2012. Only prospective randomized controlled studies that compared a nonsurgical intervention with sham or placebo therapy were included. After removal of duplicate citations, a total of 226 articles were initially identified from the search terms. From these, we identified 11 randomized controlled trials (RCTs) from which data analysis was performed. The 11 RCTs investigated traction therapy, injections, and ablative techniques. Results from 5 RCTs investigating methylene blue injection, steroid injection, ramus communicans ablation, intradiscal electrothermal therapy, and biacuplasty favored intervention over sham therapy. However, results from the study on methylene blue injections have not been replicated in other RCTs. Evaluation of the selection criteria used in the studies on ramus communicans ablation and intradiscal biacuplasty and a stratified analysis of results from the RCTs on intradiscal electrothermal therapy casts doubt on whether the conclusions from these RCTs can be applied to the general patient population with discogenic pain. There are few high-quality studies evaluating nonoperative treatments for reducing discogenic low back pain. Although conclusions from several studies favor intervention over sham, it is unclear whether these interventions confer stable long-term benefit. There is some promise in newer modalities such as biacuplasty; however, more inclusive studies need to be performed.

Editorial: Stabilization of the sacroiliac joint

Lower back pain and pain involving the area of the posterior iliac spine are extremely common. Degeneration of the sacroiliac joint (SIJ) is one potential cause for lower back pain and pain radiating into the groin or buttocks. Degenerative changes to the lumbar spine and sacroiliac joints are common. A recent study evaluating SIJ abnormalities in a primary low back pain population demonstrated 31.7% of patients demonstrated SI joint abnormalities. (4) As is the case for the evaluation and management of isolated lower back pain, the evaluation, management, and role for surgical intervention in SIJ pain is very controversial. Many patients have degenerative changes of the disc, facet joints, and SIJs. A recent systematic review performed to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint, or SIJ as the source of low back pain concluded that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. (3) It was also concluded that the usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear. (3) Although there is general agreement that SIJ pathological changes are a potential cause of pain, there is far less agreement about the optimal management of these conditions. A variety of conditions can cause SIJ dysfunction including degenerative and inflammatory arthritis, trauma, prior lumbosacral fusion, hip arthritis, limb length inequality, infections, and neoplasia. (8) There is increasing evidence that image intensifier-guided single periarticular injection can correctly localize pain to the SIJ but the optimal management strategy remains controversial. Recent publications have compared surgical versus injection treatments and fusion versus denervation procedures. (1 , 8) A systematic review found improvement regardless of the treatment, with most studies reporting over 40% improvement in pain as measured by VAS or NRS scores. (8) It cautioned that one of the studies reported 17.6% of patients experiencing mild/no pain compared with 82.4% experiencing marked/severe pain at 39 months after SIJ fusion procedures. (6 , 8) This systematic review also noted that despite improvements in reported pain, less than half of patients who had work status reported as returning to work. (8) Because of the functional and socioeconomic consequences of chronic lower back pain, numerous surgical treatments to improve this condition have been attempted by spinal surgeons through the years. Arthrodesis of the SIJ is a surgical procedure with a long history dating to the beginnings of spinal surgery. (7) Poor results, high complication rates and the need for additional surgical procedures have generally diminished the enthusiasm for this procedure until recently. (6) A variety of "minimally invasive" procedures have been recently introduced that have rekindled enthusiasm for the surgical management of SIJ pathology. The technique demonstrated in the "Stabilization of the SIJ with SI-Bone" is one of these new techniques. There has been a recent publication detailing the very short term clinical outcomes with this technique that reported encouraging results. (5) In this series of 50 patients, quality of life questionnaires were available for 49 patients preoperatively, 41 patients at 3 months, 40 at 6 months and only 27 at 12 months, complicating the ability to accurately assess true outcomes. Although the focus of this video by Geisler is on the surgical technique, there should have been more information provided on the expected surgical outcomes and potential complications of SIJ fusion. (2) The video only gives minimal information on how to appropriately select patients with potential SIJ pathology for surgical intervention. There are insufficient recommendations on the clinical and radiographic follow-up needed for this procedure. A concern with this implant is whether the porous plasma spray coating on the implant actually results in bone growth across the SIJ or only serves as a stabilizer. If true fusion does not result, deterioration in the clinical result could occur over time. This video nicely demonstrates the surgical technique of stabilization of the SIJ with SI-Bone product. There are numerous unanswered questions regarding patient selection for SIJ fusion or stabilization. There are an increasing number of surgical techniques for treating SIJ pathology and it is not clear which method may provide the best outcomes. Without prospective trials with nonconflicted surgeons and standardized selection criteria, the true role for SIJ fusion procedures in the management of chronic lower back pain will remain murky. The consequences of the unsupported enthusiasm for the surgical management of discogenic back pain still negatively impacts the public perception of spinal surgeons. Much more high quality information is needed regarding the surgical management of SIJ pathology before widespread use of this technique should be adopted.

Intradiscal Therapy

A systematic review of the medical literature regarding current intradiscal therapeutic methods. To establish an understanding of the current intradiscal treatment options for the management of low back pain. Current treatment of intradiscal disease is rapidly evolving and as such should be a multidisciplinary effort that follows a logical, orderly algorithm. Minimally invasive techniques, namely, intradiscal electrothermal therapy (IDET), radiofrequency ablation (RFA), percutaneous endoscopic laser discectomy (PELD), and cryoablation have challenged the conventional surgical management of back pain. Thirty-eight research reports, published between 1986 and 2005, were systematically reviewed for disease classification, surgical intervention, and treatment outcomes (neurologic status, pain scores, and ambulation). The surgical literature on the management of intradiscal disease continues to be limited to large series with short clinical follow-ups. Arthrodesis continues to be the primary treatment modality in the majority of patients. Newer treatment options including IDET, RFA, PELD, and cryoablation have shown promising results with regards to symptomatic relief and early return to function. Low back pain is an extremely common and potentially debilitating problem. Adding biophysical methods to well-tested biomechanical and newly investigated biomolecular solutions allows for multiple avenues of therapeutic interventions. With future clinical and basic science studies regarding intradiscal therapies forthcoming, we may soon alter our current treatment algorithms for the management of discogenic back pain.

Intradiscal electrothermal therapy in the treatment of discogenic low back pain

Chronic low back pain is a common but challenging problem for the spine specialist. Although not completely understood, the concept of a discogenic pain mechanism as a source of low back pain has been described. Discogenic low back pain may be refractory to conservative measures. This pain is typically characterized by low back pain, which is usually exacerbated by axial loading such as prolonged standing or sitting. Concurrent leg pain or lateralizing pain may likewise be present but is typically less severe than the low back pain and does not possess the typical radicular pattern of pain distribution. A discogenic etiology is suggested by a combination of this clinical presentation and a positive discogram. The pain mechanism is believed to be caused by pathologic tears of the disc annulus with subsequent irritation of nerve fibers that innervate the annulus fibrosus. 1,2 Substance P, vasoactive intestinal peptide, and calcitonin have also been identified as nociceptive neurotransmitters within these annular nerve fibers. 3 The sinuvertebral nerve and the dorsal ramus mediate the mechanical or chemical stimulation of these nociceptive fibers. Granulation tissue and neural tissue have been demonstrated within these annular tears on histopathologic specimens and thus may also play a role in discogenic pain. 4 The traditional management of discogenic low back pain has relied on conservative measures including rest, physical therapy, and oral or locally administered medications. For those patients who fail to respond to a 6-month course of these conservative measures, surgical intervention with discectomy and fusion is often considered. Surgery is expensive and is associated with a long recovery period. Spine surgery is not without complications and requires anesthesia. Disc surgery is not always successful, and repeat operations are not uncommon. Ultimately, the spinal fusion itself may not succeed in alleviating the patient’s symptoms, and nonunion may be observed. 5 An alternative treatment to spinal fusion for the management of discogenic back pain is intradiscal electrothermal therapy (IDET). 6,7 This minimally invasive procedure involves the application of thermal energy to damaged disc tissue by a percutaneously placed catheter that contains a thermal resistive coil. Thermal energy shrinks and reorients collagen fibrils and cauterizes neural and granulation tissue within the torn annulus. This promotes healing of the annulus fibrosus. Coagulation of the irritated and damage nerve fibers promotes annular denervation and contributes to pain reduction. IDET is a relatively new procedure; it received Food & Drug Administration (FDA) clearance in 1998. Preliminary results with this procedure seem to indicate reasonable safety and efficacy in properly selected patients.