Treatment Of Discogenic Back Pain Research Articles

Investigation of the in-vitro loading on an artificial spinal disk prosthesis

Spinal diseases imposes considerable burden to both patients and society. In recent years, much surgical efforts have been made in advancing the treatment of neck and back pain. Of particular prominence is the increasing clinical acceptance and use of intervertebral artificial disk prosthesis for the treatment of discogenic back pain. Despite this increased use of such disks, their in-vivo monitoring remains rudimentary. In an effort to develop an intelligent artificial spinal disk where the in-vivo loading of the spine can by studied for the first time an experimental set up has been created in order to initially study the in-vitro loading on an artificial disc prosthesis. Eight strain gauges and two piezoresistive sensors were used and placed suitably in the artificial disk prosthesis. The results from the in-vitro loading showed linear relationship between loading and the outputs from the sensors with good repeatability and less hysteresis.

Management of Symptomatic Lumbar Degenerative Disk Disease

Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicular or claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may reveal disk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.

108. Comparison of Metal-on-Metal to Metal-on-Polyethylene Material Combinations for Lumbar Total Disc Arthroplasty Under Walking Conditions

BACKGROUND CONTEXT: Lumbar disc arthroplasty is an alternative to fusion for the treatment of discogenic back pain. In contrast to spinal fusion, the total disc replacements (TDR) facilitate spinal motion at the operated level and hence maintain adjacent level kinematics. Numerous designs which incorporate different material combinations for the articulating surfaces have been introduced. The conditions under which implants are evaluated have a great impact on the wear behavior. Additionally, the wear mechanisms are not fully understood and thus complicate the evaluation of material combinations.

Review

Question: In patients with chronic low-back pain and disc degeneration, how do surgical and nonsurgical treatments compare? Data sources: MEDLINE and references of review articles. Study selection and assessment: Randomized controlled trials (RCTs) that compared surgical with nonsurgical treatment for discogenic back pain. Studies that focused specifically on comparing injections or other percutaneous treatments were not included. Study quality was assessed with use of the checklist for the Consolidated Standards of Reporting Trials. Main outcome measures: Back-specific disability. Main results: 4 RCTs (n = 783; age range, 18 to 65 y) met the inclusion criteria. Surgery in 2 RCTs consisted of posterolateral fusion with use of iliac crest autograft and a specific type of pedicle screw fixation; in 1 RCT, surgeons chose the surgical approach, implant, interbody cages, and bone-graft material; and in 1 RCT, patients were randomized to receive 1 of 3 prespecified surgical techniques: posterolateral fusion with iliac crest autograft and no fixation, posterolateral fusion with iliac crest autograft and pedicle screw fixation, or circumferential fusion consisting of posterolateral fusion and fixation supplemented with interbody fusion with use of autogenous iliac crest bone block inserted anteriorly or posteriorly. One RCT compared surgery with nonoperative care focused on physical therapy, and in 3 RCTs the control treatment was cognitive behavioral therapy addressing fears about back injury. All 4 RCTs measured disability with use of the Oswestry Disability Index (ODI) (higher score = greater disability). Across the 4 RCTs, the percent improvement from baseline ranged from 19% to 37% in the surgery group and from 5.8% to 30% in the nonoperative group. 1 RCT showed a benefit of surgery over unspecified nonoperative treatment with a difference in mean change in the ODI of 8.8 points (percent improvement 19%). The other 3 RCTs did not show a clinically meaningful difference in change in ODI score between surgery and nonoperative treatment (range: in mean change, -3.9 to 3.8%; in improvement, -9.5% to 7.5%). 2 RCTs that reported patient satisfaction showed greater success with surgery. The complication rate with surgery ranged from 9% to 18%; no complications were reported for the nonoperative group in any study. Conclusions: In patients with chronic low-back pain and disc degeneration, surgical treatment may be somewhat better than unstructured nonoperative treatment but has not been shown to be better than cognitive behavioral therapy.

Percutaneous Laser Disc Decompression in the Treatment of Discogenic Back Pain

Percutaneous Laser Disc Decompression in the Treatment of Discogenic Back Pain

Percutaneous Laser Disc Decompression in the Treatment of Discogenic Back Pain

Our aim was to evaluate the effects of percutaneous laser disc decompression (PLDD) as discogenic pain treatment using the MacNab criteria. Discogenic back pain is believed to be produced from tears in the posterior longitudinal ligament and annulus fibrosus. This pain is exacerbated through increases in intradiscal pressure via provocative discograms and transmitted through the sinuvertebral nerve. A total of 37 patients were selected based on clinical findings and provocative discograms. These patients underwent PLDD to the affected disc and were interviewed via telephone and outcome evaluated based on the MacNab criteria. Survey results revealed that 14 patients (44%) reported a good response, 14 (44%) reported a fair response, and four (12.5%) reported a poor response. The 28 patients (88%) who reported a good and fair response were considered to be successful cases. PLDD is a safe, effective, and minimally invasive procedure that can be used to treat patients with discogenic back pain.

Risk factors for failure and complications of intradiscal electrothermal therapy: a pilot study.

A bi-institutional, retrospective clinical data analysis. To determine risk factors for failure and complications of intradiscal electrothermal therapy, a treatment for discogenic back pain. Intradiscal electrothermal therapy is a relatively new treatment for discogenic back pain. Though previous studies have shown it to be an effective treatment, there are few published studies examining complications and none examining risk factors for failure. The authors treated 79 patients with discogenic back pain using intradiscal electrothermal therapy. Complications were assessed by patient report and, when indicated, further diagnostic testing. Success or failure was determined by visual analogue pain scores at 6-month follow-up. Variables examined for their relationship to failure and complications were age, sex, duration of pain, number of levels heated, smoking history, diabetes, obesity, leg pain, and previous back surgery. Forty-eight percent of patients reported more than 50% pain relief at their 6-month follow-up. There were eight complications (10%), most of which were self-limited and transient. The only risk factor associated with intradiscal electrothermal therapy failure was obesity (P = 0.01). Whereas 54% of nonobese patients reported good pain relief at 6 months, only one out of 10 obese patients had successful intradiscal electrothermal therapy. The obese patients in our study were more likely to have a complication from intradiscal electrothermal therapy than they were to obtain pain relief. The only risk factor found to be associated with IDET outcome was obesity, which was a strong predictor of failure. Obesity should be considered a relative contraindication to performing IDET.

Lumbar interbody fusion comparing allograft bone dowels with threaded titanium cages: a prospective, randomized, multicenter study

Frank M. Phillips, MD, Chicago, IL, USA; Mark Falahee, MD, Ypsilanti, MI, USA; F. Todd Wetzel, MD, Chicago, IL, USA; Richard Rabinowitz, MD, Hoffman Estates, IL, USA; Purnendu Gupta, MD, Chicago, IL, USAPurpose: Stand alone lumbar interbody fusion has been used as a treatment for symptomatic lumbar spondylosis using both allograft bone dowels and threaded titanium cages. This paper reports findings of a randomized, prospective multicenter study that assesses results of interbody fusion using threaded bone dowels or titanium cages with autograft for the treatment of discogenic low back pain unresponsive to conservative treatment measuring both fusion parameters and patient-centered outcomes.Materials and methods: This multicenter, randomized, prospective study enrolled 60 patients at five study sites from April 1998 to July 2000. Fifty-six patients advanced beyond the enrollment period. All study patients had mechanical low back pain greater than leg pain with the disc confirmed as source of the pain by provocative discography. Patients were between 18 and 65 years old and had failed at least 6 months of conservative care. Up to grade 1 degenerative spondylolisthesis at the involved level was allowed for inclusion into the study. One- or two-level stand alone interbody fusion was performed using either threaded allograft bone dowels or threaded titanium cages with autograft with patients randomized at each study site into one of these two groups. No supplemental instrumentation was used. Fusion outcome was assessed at 12 months by anteroposterior, lateral and flexion-extension views. Patient functional outcomes were assessed by SF-36 and Oswestry scale measurements at enrollment, 6- and 12-month intervals collected independent of the physician's office.Results: A total of 28 patients completed 1-year follow-up X-ray evaluation with 35 total interbody fusion sites. Overall, 24 patients and 30 interbody sites were judged by independent radiologic assessment as fused, with 3 patients and four interbody levels judged as indeterminate and 1 patient with one interbody level judged a fusion failure. Assuming all indeterminate levels were considered nonfused, the series would have a 85.7% fusion rate for all patients and 85.7% fusion for all interbody sites. In the threaded bone dowel group of 13 patients and 15 interbody sites, all sites were judged fused. Of the 15 patients and 20 interbody sites treated with threaded titanium cages, 11 patients and 15 sites were judged fused with 3 patients and 4 interbody sites judged indeterminate, and 1 site/patient a failure to fuse.Thirty patients completed the 12-month postoperative clinical outcome survey. Statistical analysis was carried out to evaluate the Short Form (SF)-36, Oswestry and Pain scores for both groups comparing preoperative and 12-month postoperative scores. For both the threaded bone dowel group and the threaded titanium cage group, statistically significant changes indicating improvement were found for the SF-36 scores for Physical Functioning (p=.0033), Role Limitations-Physical (p=.00001), Social Functioning (p=.0009). Bodily Pain (p=.00001), Vitality (p=.00001) and PCS (p=.00001) as well as for the Oswestry Disability Index (preoperative mean, 51.78; postoperative mean, 33.05; p=.00001) and Back Pain Visual Analog Scale (preoperative mean, 7.64; postoperative mean, 4.56; p=.0001). Although both the threaded bone dowel group and the threaded titanium cage group showed statistically significant clinical improvement, there was no statistical difference that was detected in the scores for any of the outcome parameters between the threaded bone dowel and titanium cage groups.Discussion: Stand alone interbody fusion using both threaded bone dowels and threaded titanium cages was found an acceptable treatment for discogenic back pain that had failed conservative care. Clinical results showed statistically significant improvement in patient-centered outcomes using both fusion options. No significant differences in clinical outcomes were detected between the two groups. Radiological assessment of fusion was determined more definitively when threaded bone dowels were used for interbody fusion. It is unclear whether the threaded titanium cages deemed to have an indeterminate fusion status had indeed failed to fuse or if it was simply not possible to interpret the fusion on the radiographic studies.

Intradiscal electrothermal therapy for the treatment of discogenic back pain

Intradiscal electrothermal therapy for the treatment of discogenic back pain

CHEMON UCLEOLYSIS

This paper attempts to answer the controversial question, namely, how effective is chemonucleolysis in the treatment of discogenic back pain and sciatica? By using a type of double-blind study, a comparison has been made between 20 patients who were treated with chemonucleolysis and 20 who were treated with intra-discal hydrocortisone. The 2 year post-injection survey by an independent observer, demonstrated that chemonucleolysis produced 9 good, 3 fair, and 8 unimproved results in 20 patients. In contrast, hydrocortisone produced 3 good, 8 fair, and 8 unimproved results in 20 patients - one patient dying from unrelated causes. Although not statistically significant, the data suggest that chemonucleolysis was superior to intra-discal hydrocortisone in this series.