Trial Of Conservative Treatment Research Articles

Hiatal Hernia in Pediatric Gastroesophageal Reflux

This study compares esophageal pH-monitoring parameters of children with gastroesophageal reflux (GER) with or without hiatal hernia (HH) and determines the outcome of those with GER and HH. Among 718 children with GER, 45 children (6%) with associated HH were retrospectively studied. They were divided into those with neurologically normal development (NN, n = 35) and those with neurologic disorders (ND, n = 10). The pH-monitoring parameters of 27 of these (60%) were compared with pH-monitoring parameters of 27 control children who had GER without HH. Esophageal clearance was longer in patients with HH compared with those without HH (P < 0.05). All 35 NN patients underwent a trial of conservative treatment, which failed in 9 patients (25.7%). Surgery was the initial treatment in 8 ND patients. Follow-up was available in 20 NN and 10 ND patients. Nine of 11 conservatively treated NN patients improved. All NN (n = 9) and ND (n = 8) patients who underwent surgery improved. Conservative treatment failed in 2 NN and in 2 ND patients. Presence of HH in children with GER is associated with prolonged exposure of the esophagus to acid and a high failure rate of nonoperative treatment. However, medical treatment should be tried in NN children despite the significant failure rate.

Surgical management of peptic ulcer disease today--indication, technique and outcome.

The current surgical management of peptic ulcer disease and its outcome have been reviewed. Today, surgery for peptic ulcer disease is largely restricted to the treatment of complications. In peptic ulcer perforation, a conservative treatment trial can be given in selected cases. If laparotomy is necessary, simple closure is sufficient in the large majority of cases, and definitive ulcer surgery to reduce gastric acid secretion is no longer justified in these patients. Laparoscopic surgery for perforated peptic ulcer has failed to prove to be a significant advantage over open surgery. In bleeding peptic ulcers, definitive hemostasis can be achieved by endoscopic treatment in more than 90% of cases. In 1-2% of cases, immediate emergency surgery is necessary. Some ulcers have a high risk of re-bleeding, and early elective surgery might be advisable. Surgical bleeding control can be achieved by direct suture and extraluminal ligation of the gastroduodenal artery or by gastric resection. Benign gastric outlet obstruction can be controlled by endoscopic balloon dilatation in 70% of cases, but gastrojejunostomy or gastric resection are necessary in about 30% of cases. Elective surgery for peptic ulcer disease has been largely abandoned, and bleeding or obstructing ulcers can be managed safely by endoscopic treatment in most cases. However, surgeons will continue to encounter patients with peptic ulcer disease for emergency surgery. Currently, laparoscopic surgery has no proven advantage in peptic ulcer surgery.

WRIST PAIN IN A GYMNAST WITH PRIMARY AMENORRHEA

285 DIFFERENTIAL DIAGNOSIS: Wrist pain Distal radius physeal stress reaction Triangular fibrocartilage complex tear Ulnar impaction syndrome Carpal impingement Delayed Menarche Hypothalamic cause (Exercise associated amenorrhea (EAA)) Consitutional delay Ovarian failure Thyroid disease Prolactinoma TESTS AND RESULTS: Bilateral wrist x-rays Open growth plates consistent with bone age of 11-12 yo Non-union of left ulnar styloid Positive ulnar variance Cyst on distal ulnar and raidal physes Sclerosis of distal radial physes Suggestion of widening of radial aspect of distal radial physes FSH: 8 mIU/ml Estradiol: 61 pg/ml TSH: 2 mIU/ml Chemistry panel and CBC: WNL DEXA: Borderline osteopenia of femoral neck FINAL WORKING DIAGNOSES: Delayed menarche secondary to EAA and constitutional delay Distal radius physeal stress reaction with positive ulnar variance Ulnar impaction syndrome Possible right TFCC tear TREATMENT: A trial of decrease upper extremity weight bearing. Wear wrist extension blocking brace. Consider surgical options after further evaluation and a trial of conservative treatment. Monitor menstrual cycles. Review diet for adequate intake of calories, calcium and vitamin D HISTORY: A 18 year old elite female gymnast presents for preparticipation physicals without any complaints. Her medical history reveals that she has not yet undergone menarche. She denies a history of disordered eating behaviors and stress fractures. She has been a gymnast for 13 years and trains 20 hrs/wk. Orthopedic history is significant for ankle arthroscopy for loose body removal in 1994 and rotator cuff tear and repair in 1996. Review of systems is unremarkable for temperature intolerance, bowel changes, palpitations, dry hair or skin, nipple discharge, headaches, visual changes, male pattern hair growth or acne. No history of abdominal or pelvic pain. She is not sexually active. PHYSICAL EXAMINATION: Ht: 4 ft 10 in Wt: 98 lbs VS: WNL Thyroid: WNL Breasts: Tanner stage 3 Skin: No male pattern hair growth, acne or striae Wrists: Marked prominence of the distal ulnas; bilateral diffuse tenderness of the distal ulna and radius and ulnocarpal joint; radioulnar joint nontender; pain reproduced with wrist extension and axial loading; limited extension to 50 degrees bilaterally; audible click with right ulnar deviation; no other bony tenderness. Pelvic: Tanner stage 3; WNL (Note: Menarche occurred prior to the pelvic exam which was performed subsequent to PPE.) HISTORY: (Additional history was sought due to abnormal physical findings) Despite not offering a history of wrist pain, she admitted to having wrist pain for many years and felt it was slowly worsening. Pain occurs with vaulting, tumbling and uneven bar skills that require an inverted grip (extreme wrist pronation and ulnar deviation). She was told that "she may have a problem with her growth plates" following x-rays 8 months ago.

A Population Based, Randomized, Controlled Trial of Conservative Treatment for Urinary Incontinence in Women

A Population Based, Randomized, Controlled Trial of Conservative Treatment for Urinary Incontinence in Women

A Population Based, Randomized, Controlled Trial of Conservative Treatment for Urinary Incontinence in Women

Background. Urinary incontinence remains a hidden and inadequately treated problem in a high proportion of women.Methods. Ninety women 50–74 years of age were recruited to a population-based, randomized, controlled clinical trial of conservative treatment for urinary incontinence, with delayed treatment for the control group. The study was performed in general practice in three north-Norwegian municipalities, in cooperation with two local departments of gynecology. Three patients were found protocol deviant and analysis was based on 87 patients.Intervention. Local estrogen, physiotherapy and electrostimulation combined with close follow-up.Main outcome measures. 1. Change in severity of incontinence from start of treatment (index range 0–8). 2. Change in impact from start of treatment (index range 0–4). 3. Quantitative measures in relation to micturition. 4. Criteria based classification into cured, improved, unchanged, worse.Results. Treatment reduced severity (index change 1.8 in the intervention group v...

Vaginal weights for assessment and training of the pelvic floor

Urinary incontinence is a common problem for women. A trial of conservative treatment is frequently suggested before considering other treatment options. One method involves the use of vaginal weights for retraining the pelvic floor muscle. This review examines articles and abstracts on vaginal weights published in English or with abstracts in English between 1985 and 1997. It concludes that, despite some practical and theoretic concerns, there is adequate clinical evidence to support the use of weights in selected populations. Weights may be an effective training aid for women with mild to moderate stress incontinence, particularly in the absence of severe pelvic organ prolapse. They also may be useful for pelvic floor strengthening during the immediate postpartum period, as a behavioral program for continence maintenance, and for self-management programs. Suggestions for further research to refine treatment parameters and client selection are also presented.

Interventions for isolated diaphyseal fractures of the ulna in adults.

Isolated fractures of the shaft of the ulna, which are often sustained when the forearm is raised to shield against a blow, are generally treated on an out-patient basis. To assess the effects of various forms of treatment for isolated fractures of the ulnar shaft in adults. We searched the Cochrane Musculoskeletal Injuries Group's specialised register (December 2000), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1981 to December 2000), CINAHL (1982 to December 2000), and bibliographies of trial reports. Date of the most recent search: December 2000. Randomised or quasi-randomised trials of conservative and surgical treatment of isolated fractures of the ulnar shaft in adults. Excluded were fractures of the proximal ulna and Monteggia fracture dislocations. Independent quality assessment and data extraction were performed by all reviewers. Requests for more information were sent to trialists. Given the limited and poor quality evidence available, quantitative analysis was kept to a minimum. In the second update of this review, the only newly identified trial was excluded. Thus, as before, two small trials of conservative treatment, involving a total of 106 patients were included in this review. Both trials were of poor quality. One randomised trial compared short arm pre-fabricated functional braces with long arm plaster casts. There was no statistically significant difference in the time it took for fracture union. Patient satisfaction and return to work were better in the brace group. The other quasi-randomised trial compared Ace Wrap elastic bandage, short arm plaster cast and long arm plaster cast. The large loss to follow-up in this trial makes any data analysis tentative. However the need for replacement of the Ace wrap by other methods due to pain does indicate the potential for a serious problem with this intervention. There is insufficient evidence from randomised trials to determine which method of treatment is the most appropriate for isolated fractures of the ulnar shaft in adults. There is a need to establish the incidence of this injury and the outcome and associated costs of the various forms of treatment. Well designed randomised trials of current forms of conservative treatment are recommended.

Arthroscopic treatment of anterior ankle impingement.

Ankle arthroscopy has recently allowed the elaboration of less invasive techniques for the treatment of anterior impingement. Its indications, advantages, and drawbacks in this application are discussed. Between 1987 and 1994, 133 patients were treated for ankle impingement. Among them, 58 patients, 37 men and 21 women (mean age, 28.5 years), who had failed a trial of conservative treatment were treated by means of tibiotalar arthroscopy. Twenty-seven were athletes engaged in sports with abnormal stressing of the ankle. According to McDermott's radiological classification, there were 15 stage I cases, 23 stage II, 13 stage III, and 7 stage IV. Preoperative evaluation with a modified version of McGuire's scoring system gave 50 cases rated as "poor" (< 60 points) and 8 cases rated as "fair" (60-67 points). Treatment consisted of removal of adhesions, cartilage shaving, and removal of the bone impingement with powered instruments, curettes, or small osteotomes. Follow-up was from 8 to 62 months (mean, 21.5 months). The postoperative McGuire ratings were 37 good, 13 fair, and 8 poor. There were no major complications. Recurrence of impingement was observed in four cases of stage III and IV. The conclusion is drawn that ankle arthroscopy is a sound method for the treatment of anterior impingement. Even in cases with severe joint cartilage impairment, it plays a therapeutic role as a means of postponing a possible arthrodesis.

Injection treatment in non-radicular low back pain

Low back pain is the most expensive condition in industrialized countries. Approximately 65–80 % of the population will be afflicted with low back pain at some point during their life. Low back pain has many causes and can originate from any of several pain-sensitive foci, among which are facet joints, sacroiliac joint, muscle and ligaments. Primary care in the acute phase consists of nonsteroidal anti-inflammatory drugs to address the biochemical and inflammatory mediators of pain or skeletal muscle spasmolytics to reduce low back pain symptoms. Injection procedures should be reserved for the patients with low back pain who fail to respond to a directed, conservative treatment trial and have had pain for at least 2 weeks' duration. Eliminating sensation from a certain pain source has been proposed as a way to allow an examiner to determine if that joint is responsible for the patient's pain. Injections of local anesthetic into the facet joint or around its nerve supply are clinical methods of eliminating pain from focal areas such as facet joints or myofascial trigger points. When a particular joint is determined to be the source of pain, long-term relief can be sought by directing therapeutic interventions at that joint. The anatomic accessibility of the most common pain sources of low back pain make diagnostic blocks and therapeutic instillation of corticosteroids particularly appealing. If used, their potential benefit for the individual case needs to be carefully weighed. They should be used to facilitate more aggressive conservative care and not as an isolated treatment. Certainly, if response to corticosteroids does not occur after the first injection, no further administration of corticosteroids is indicated.

Persistent pain: Cognitive-behavioral approaches to assessment and treatment

.M. IS A 49-year-old woman who has had persistent lower back pain for 5 years. She first injured her back when she moved to the Durham area. During the move, she was lifting a box and turning to pass it to her husband when she felt excruciating pain in her lower back and radiating down her right leg. After a 3-week trial of conservative treatment, she went to see an orthopedic surgeon and was found to have a large herniated disc at L4-5. She had a laminectomy, which reduced her leg pain somewhat but had no effect on her lower back pain. The back pain

Injection treatment of non-radicular lumbalgia

Low back pain is the most expensive condition in industrialized countries. Approximately 65-80% of the population will be afflicted with low back pain at some point during their life. Low back pain has many causes and can originate from any of several pain-sensitive foci, among which are facet joints, sacroiliac joint, muscle and ligaments. Primary care in the acute phase consists of nonsteroidal anti-inflammatory drugs to address the biochemical and inflammatory mediators of pain or skeletal muscle spasmolytics to reduce low back pain symptoms. Injection procedures should be reserved for the patients with low back pain who fail to respond to a directed, conservative treatment trial and have had pain for at least 2 weeks duration. Eliminating sensation from a certain pain source has been proposed as a way to allow an examiner to determine if that joint is responsible for the patient's pain. Injections of local anesthetic into the facet joint or around its nerve supply are clinical methods of eliminating pain from focal areas such as facet joints or myofascial trigger points. When a particular joint is determined to be the source of pain, long-term relief can be sought by directing therapeutic interventions at that joint. The anatomic accessibility of the most common pain sources of low back pain make diagnostic blocks and therapeutic instillation of corticosteroids particularly appealing. If used, their potential benefit for the individual case needs to be carefully weighed. They should be used to facilitate more aggressive conservative care and not as an isolated treatment. Certainly, if response to corticosteroids does not occur after the first injection, no further administration of corticosteroids is indicated.

Success of calcaneonavicular coalition resection in the adult population.

Twelve adult patients (13 feet), average age 33 years (range, 19-48 years), with calcaneonavicular coalitions remained symptomatic after a trial of conservative treatment. Surgical resections were performed. Before surgery, there was < 5 degrees of inversion/eversion in 11 patients, radiographic evidence of degenerative arthritis in 10 feet (77%), and talar beaking in 7 feet. At an average postoperative follow-up of 36 months, subjective relief of preoperative symptoms was achieved in all but two patients. Two patients required subsequent hindfoot arthrodesis. Resection of calcaneonavicular coalition in the adult can be successful and provides an option to arthrodesis after nonoperative methods have failed.

Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis.

Previous studies describing nonconservative treatment of shoulder adhesive capsulitis include distention arthrography, brisement techniques, arthrotomy of the anterior/inferior axillary fold and subscapularis tendon, and manipulation under general anesthesia. The purpose of this study was to develop and describe an alternative treatment method that utilizes glide manipulation under interscalene brachial plexus block. Eight patients (four females and four males), age 31-55 years, with a mean age of 44 years, were treated conservatively for adhesive capsulitis of the shoulder and failed to produce increased measurable objective active or passive ranges of motion. Symptoms of adhesive capsulitis in these patients range from 3 to 16 months, 7 months average. Premanipulation treatment ranged from 1 to 21 weeks, with an average of 9 weeks. Two additional patients were considered for manipulation after a trial of conservative treatment, but the interscalene brachial plexus block and manipulation were not performed. One patient was eliminated from the study due to excessive osteoarthritis in the shoulder girdle, and the other patient was eliminated from the study due to a high cardiac risk. The eight patients chosen for manipulation underwent interscalene brachial plexus blocks. They were immediately sent to the physical therapist for manipulation under anesthesia following the interscalene brachial plexus blocks. Immediately following manipulation, the average increases in passive range of motion for flexion, abduction, external rotation, and internal rotation were 68 degrees, 77 degrees, 49 degrees, and 45 degrees, respectively. At the time of discharge, average increases in passive range of motion/active range of motion for flexion, abduction, external rotation, and internal rotation were 76/67 degrees, 82/73 degrees, 50/44 degrees, and 49/40 degrees, respectively. All patients manipulated showed increases in function, such as overhead activities, dressing activities, and hair care. These preliminary findings show that effective gliding manipulation can be carried out under regional blockade and performed in an office setting by practitioners knowledgeable in manipulation techniques.

Bio-histochemical aspects of integrins (alpha 2 beta 1, alpha 6 beta 1) in invasive mammary carcinomas: an immunohistochemical study.

Immunohistochemical expression of integrins was examined in 39 human invasive mammary carcinomas, of which 34.2% and 43.6% expressed integrins alpha 2 beta 1 and alpha 6 beta 1, respectively. Immuno-electron microscopy clearly demonstrated that the integrins were in the cell membrane of the carcinoma cells. Similar expression of integrin alpha 2 beta 1 or alpha 6 beta 1 in both the intraductal component and invasive portion of the same tumor was seen in 76.9% and 85.7% of cases, respectively. This suggested that invasive carcinoma cells retained their integrin expression after invasion through the basement membrane. Reciprocal expression of integrins alpha 2 beta 1 and alpha 6 beta 1 was seen in 20 cases. Expression of alpha 2 beta 1 was seen significantly less frequently in scirrhous carcinoma than in the more differentiated papillotubular or solid tubular carcinoma (Chi-squared test, P < 0.05). Intraductal components of carcinoma were present more frequently in cases expressing integrin alpha 2 beta 1 than in those that were negative. This suggests the potential usefulness of integrins as clinical parameters in the surgical treatment of mammary carcinoma, since recent trials of conservative treatment for mammary carcinoma have focused on the intraductal spread of the tumor cells.

The impact of managed care on the diagnosis and treatment of low back pain: a preliminary report.

Knowing when to use diagnostic testing and surgery in the management of low back pain is often a dilemma for practitioners. This paper reviews the effectiveness of clinical practice guidelines in managing 1,796 cases of low back pain or herniated lumbar disk reviewed by Health Risk Management, Inc. between November 1990 and October 1991. In all cases (except cauda equina syndrome or other rapidly progressing neurological deficit) a trial of conservative treatment, always including physical therapy, was requested prior to recommendation for diagnostic testing or surgery. Ninety-one percent (1,628 cases) had completed an adequate trial of conservative therapy or had a lesion requiring immediate intervention. These cases were recommended for the requested procedure or hospitalization. Of the 168 cases that were not recommended immediately for imaging, surgery, or hospitalization, 84.5% improved with conservative management and neither imaging nor surgery was necessary over a period of at least 12 months following the time of review. Efficacy of conservative management was independent of age, sex, part of the country in which the treatment took place, and primary diagnosis. Net savings realized after subtracting employer costs for the reviews were well over a third of a million dollars in this small group of patients.

Medial Approach Open Reduction Without Preliminary Traction for Congenital Dislocation of the Hip

We examined the results of medial approach open reduction without preliminary traction or attempt at closed reduction for congenital dislocation of the hip (CDH) in children aged <1 year prospectively. In all children, a trial of conservative treatment with Pavlik harness failed. Twenty-three hips in 19 children were treated. Follow-up ranged from 5 to 10 years (average 8 years). None of the hips redislocated. Osteonecrosis of the femoral head occurred in one patient with coxa magna. Two children subsequently underwent Salter innominate osteotomy for hip dysplasia. Early detection and treatment with Pavlik harness is our preferred approach to treatment of CDH. In children who have failed initial harness management, medial approach open reduction without preliminary traction affords a safe, effective, and relatively simple alternative to other methods of treatment.

Reply

In conclusion, the authors' recommendation of MR imaging for all patients seems unreasonable to us. Seidenwurm et al present an understandable criticism that a large proportion of our patients (78 of 95 patients) did come from surgical clinics and that more patients received surgical treatment (56 of 95 patients) than conservative treatment (39 of 95 patients). This might be construed to bias our study. As we noted earlier, we believe that this directs the study results specifically to the patient population for which it is most relevant (ie, those in whom imaging is indicated after an initial adequate trial of conservative treatment). In this decision environment, we submit that our data analysis and recommendations are valid (not flawed), based on the results of our study and examination costs like those at our institution. The authors should find encouragement in our statement on page 738 (2) that MR imaging will be an acceptable replacement for plain CT in patients with low probability of HNPNC when the cost of MR imaging decreases and approaches that of plain CT. This has happened recently in California. In that case, as we stated in our report, we would agree with Seidenwurm et al that plain CT can be replaced by MR imaging. We hope that future commentary on our report will be more to the point scientifically and not rely on rhetoric and anecdotal evidence in place of comparative data like ours. The protocol of our study was the least biased, most rigorous methodology-based one that we could devise. As such, the study appears to be a rarity in the previous literature on the diagnostic accuracy of MR imaging and CT examination of the spine (2). One of our underlying aims has been to put radiologists who perform radiologic imaging technology assessment in a stronger position to compete with non-radiologists for grant support at the national level. We have secured peer-reviewed grant support for our multidisciplinary team and hope that other radiologists will become successful in use of such rigorous research methods. It is appropriate to recall the prophetic comment by Fineberg (19), which remains as appropriate today as in 1978, when he stated the following: Evaluation of CT, or of any dynamic medical technology, will never provide final answers. Findings will be open to interpretation. Individual values and judgments will always play a role. Decisions about the development, reimbursement, and use of new technologies will continue to be made, however imperfectly. The great challenge, embodied in CT but embracing all of medicine, is to bring policy and practice into line with knowledge. Useful knowledge, we submit, is knowledge based on the least biased evidence with the highest scientific quality available.

Focal nodular hyperplasia of the liver: results of treatment and options in management.

Twenty two patients (19 females) with focal nodular hyperplasia were seen between 1973 and 1989. Five were children, and all the adults were aged under 42 years (median 33 years). Fourteen patients (64%) were symptomatic on presentation. Twelve of the 14 adult women had taken the oral contraceptive pill. Twelve patients, nine of whom were symptomatic, underwent hepatic resection shortly after presentation. There were no deaths or major complications, and all remain well on follow up. Four patients underwent either hepatic artery embolisation or ligation. After an interval of six to 10 years they were asymptomatic and only one has histological evidence of residual focal nodular hyperplasia. Of five patients initially treated conservatively, two were asymptomatic and have remained so for three and 13 years. One of the three symptomatic patients became symptom free after stopping the contraceptive pill. The management of focal nodular hyperplasia requires a flexible approach. Lesions which are asymptomatic can be observed with regular ultrasound and treated if they enlarge or become symptomatic. Symptomatic patients who present while taking the contraceptive pill can also have a trial of conservative treatment. Other symptomatic patients, including those who previously took the pill, are best treated by surgical resection, and, where this is not possible, by embolisation.

Conservative Treatment of Patients with Acoustic Tumors

Abstract Seventy of 178 patients with acoustic tumors initially were treated conservatively and have been followed up for an average of 26 ± 2 months. The tumor size was determined by the mean maximum anteroposterior and mediolateral diameters, using computed tomographic or magnetic resonance imaging scans obtained sequentially throughout the follow-up period. The average tumor growth was 1.6 ± 0.4 mm the 1st year, and 1.9 ± 1.0 mm the 2nd year (range, -2 to 17 mm/y): 4 tumors showed apparent regression, 28 (40%) had no detectable growth, and 37 (53%) exhibited growth (average, 3.8 ± 1.2 mm/y). Within individual patients, the tumor growth rate determined during the 1st year of follow-up was predictive of tumor growth rate during the following year. Rapid tumor growth or clinical deterioration in 9 of the 70 patients (13%) who initially were treated conservatively necessitated subsequent surgery an average of 14 ± 5 months after the patient was initially seen. This group had a larger initial tumor size (27.0 ± 3.4 mm vs. 21.3 ± 0.9 mm, P&amp;lt;0.05), and a faster 1-year growth rate (7.9 ± 2.3 mm/y vs. 1.3 ± 0.3 mm/y, P&amp;lt;0.05) than the 61 patients who did not require surgery. Two patients, however, experienced neurological deterioration that required surgery, even though there was no tumor growth. The high incidence of acoustic tumors with no detectable growth or apparent spontaneous regression must be taken into account when evaluating the indications for surgery and the efficacy of radiotherapy. Beacuse surgery carries some risk and acoustic tumors are generally slow growing, a trial of conservative treatment is possible in selected patients, provided serial radiological studies are obtained. Knowledge of the tumor growth rate established by these studies may be helpful in the treatment of individual patients.

Anterior and Combined Anteroposterior Fusion for Lumbar Disc Pain A Preliminary Study

This article reports on a study of 51 consecutive patients (83 lumbar discs) with back pain who underwent anterior interbody lumbar fusion or combined anterior and posterior fusion at the same operation during a 2-year period. All patients met the criteria for diagnosis of a painful internal disc disruption and/or failed back syndrome and have had a lengthy trial of conservative treatment consisting of rest, physical therapy, back support, nonsteroidal anti-inflammatory drug therapy, and guarded activity; this treatment was often supplemented by epidural cortisone injections, pain management, and functional rehabilitation. Patients with prolonged back pain who failed with conservative care after a minimum of 12 months of severely disabling symptoms were selected for surgery on the basis of a positive dynamic discogram reproducing their exact pain and demonstrating a morphologically degenerative disc (internal disc disruption). For the purpose of this study, patients were categorized into three groups and followed up for 15-36 months after the operation. There were no deaths or major complications, and the overall success in achieving measurable diminution of preoperative pain was 80%. This article discusses preliminary conclusions on the efficacy and safety on anterior and anteroposterior fusion for lumbar disc pain.