Intradiscal electrothermal treatment for chronic discogenic low back pain: a prospective outcome study with minimum 1-year follow-up.

STUDY DESIGN: Prospective case series. OBJECTIVE: To determine the outcome of patients with chronic low back pain whose symptoms did not improve with aggressive nonoperative care and who chose (intradiscal electrothermal anuloplasty) IDET as an alternative to chronic pain management or interbody fusion surgery. SUMMARY OF BACKGROUND DATA: Patients with unremitting chronic discogenic low back pain are faced with the choice of long-term pain management or fusion surgery. Intradiscal electrothermal anuloplasty (IDET) was developed as an alternative minimally invasive treatment. MATERIALS AND METHODS: Sixty-two patients from the author's practice who had chronic low back pain unresponsive to nonoperative care, no evidence of compressive radiculopathy, and concordant pain reproduction at one or more disc levels on provocative discography were enrolled in the study. Visual analog scale (VAS) pain scores and Short Form (SF)-36 Health Status Questionnaire Physical Function subscale and SF-36 Bodily Pain subscale scores were assessed at baseline and at least 1 year later. RESULTS: Mean follow-up was 16 months, and mean preoperative duration of symptoms was 60 months. Baseline and follow-up outcome measures demonstrated a mean change in VAS score of 3.0 (P < 0.001), mean change in SF-36 physical function of 20 (P < 0.001), and mean change in SF-36 bodily pain of 17 (P < 0.001). Symptoms improved in 44 (71%) of 62 of the study group on the SF-36 physical function subscale, in 46 (74%) of 62 on the SF-36 Bodily Pain subscale, and in 44 (71%) of 62 on the VAS scores. Twelve (19%) of 62 of the patients did not show improvement on any scale. CONCLUSION: A cohort of patients with chronic unremitting low back pain of discogenic origin whose symptoms had failed to improve with aggressive nonoperative care demonstrated a statistically significant and clinically meaningful improvement on the SF-36 and the VAS scores at a minimum follow-up of 1 year after IDET. The positive results should be validated with placebo-controlled randomized trials and studies that compare IDET with alternative treatments.-

Management of chronic discogenic low back pain with a thermal intradiscal catheter. A preliminary report.

STUDY DESIGN: A prospective nonrandomized clinical trial. OBJECTIVE: To determine the outcome in a group of patients with chronic, function-limiting low back pain who met the criteria for interbody fusion surgery, but were instead treated with an intradiscal thermal catheter (SpineCath, Oratec Interventions, Inc., Menlo Park, CA). SUMMARY OF BACKGROUND DATA: This study represents the first reported trial of treatment for chronic discogenic low back pain with a novel thermal intradiscal catheter. METHODS: The authors evaluated 25 consecutive patients. The minimum duration of nonoperative care with the authors was 6 months. The visual analog pain scores, sitting tolerance times, and SF-36 summary scores were tabulated. RESULTS: The mean follow-up period was 7 months, and the mean duration of symptoms 58.5 months. Of the 25 patients, 20 (80%) reported a reduction of at least 2 points in visual analog pain scores, and 18 (72%) reported an improvement in sitting tolerance as well as reduction or discontinuance of analgesic medication. Visual analog pain scores improved by a mean reduction of 3.74, a 51% change (P = 0.0001). On the SF-36 physical function subscale, 72% of the patients improved by a mean increase of 15 points (P = 0.001), a mean change of 38%, and by a mean increase of 14 points on the bodily pain subscale (P = 0.004), a mean change of 48%. CONCLUSIONS: A statistically significant improvement in functional outcome was obtained in patients with chronic discogenic low back pain treated thermally by the SpineCath.

Natural history and nonoperative treatment of lumbar disc herniation.

Lumbar disc herniation is a common condition with a favorable prognosis in the majority of circumstances. This article reviews the published scientific evidence regarding the impact of nonoperative care on this condition. The published studies are critiqued and evaluated on their relative strengths and weaknesses. The effect of time, medications, exercise, injection therapy, and manipulation are considered. The literature regarding the natural history process of disc resorption is reviewed, including time frames and the proposed underlying mechanisms that may enhance or impede this process. The effect of inflammation on treatment effectiveness and decision-making is evaluated. The possible impact of various types and locations of lumbar disc herniation, coexisting anatomic factors, lumbar disc herniation material type, lumbar disc herniation material chemical factors, clinical characteristics, and patient-related factors are discussed. Appropriate candidates for operative versus nonoperative care are discussed. Conclusions are drawn from this literature review that will help guide management decisions.

Consensus summary of the diagnosis and treatment of lumbar disc herniation.

Clinicians must not simply decide that a patient with symptoms and a positive diagnostic test has a reason for a specific treatment, and likewise clinicians must not decide that a patient with symptoms and a negative test does not have a clinically important problem. We must also consider the sensitivity, specificity and predictive value of the diagnostic test and the individual characteristics of the patient. Treatment outcome depends on many factors. Point of service decisions vs population based decisions are obviously different. Each patient presents to the treating practitioner on a given day, at a given time, and it is this picture upon which a plan of care is formulated.

Nonoperative management of herniated cervical intervertebral disc with radiculopathy.

STUDY DESIGN: A longitudinal cohort study design was used. All patients underwent a systematically and uniformly applied treatment program with increasing intervention as further pain control was needed. All patients were followed up by questionnaire evaluating function and symptoms. OBJECTIVES: The role of surgical versus nonsurgical treatment of patients with cervical disc herniation has not been adequately studied. The majority of published data reflects surgical outcomes, with little available data regarding the outcome of nonoperatively treated patients. Frequently, these patients are treated surgically if they have neurologic loss or radiculopathy that persists after rest or minimal intervention. In the authors' clinic, patients with cervical herniated nucleus pulposus and radiculopathy are treated with an aggressive physical rehabilitation program. SUMMARY OF BACKGROUND DATA: All patients treated by the authors during a specified time period with a clearly defined diagnosis of cervical herniated nucleus pulposus were evaluated for outcome. METHODS: Twenty-six consecutive patients with cervical herniated nucleus pulposus and radiculopathy were evaluated by an investigator other than the treating physician. The follow-up time was more than 1 year in all patients. Data analyzed included symptom level, activity and function level, medication and ongoing medical care, job status, and satisfaction. Inclusion criteria included a focal cervical disc protrusion of less than 4 mm identified on magnetic resonance imaging and a major complaint of extremity pain compatible with cervical radiculopathy. Exclusion criteria included severe central canal stenosis, symptomatic cervical myelopathy, or condition that precluded participation in the rehabilitation program. Management consisted of traction, specific physical therapeutic exercise, oral anti-inflammatory medication, and patient education. The majority of patients presented with neurologic loss. RESULTS: Twenty-four patients were successfully treated without surgery. Twenty patients achieved a good or excellent outcome of these 19 had disc extrusions. Two patients underwent cervical spine surgery. Twenty-one patients returned to the same job. One patient retired. CONCLUSION: Many cervical disc herniations can be successfully managed with aggressive nonsurgical treatment (24 of 26 in the present study). Progressive neurologic loss did not occur in any patient, and most patients were able to continue with their preinjury activities with little limitation. High patient satisfaction with nonoperative care was achieved on outcome analysis.

Human disc phospholipase A2 is inflammatory.

Human discs have been demonstrated to contain high levels of phospholipase A2. As the enzyme responsible for the liberation of arachidonic acid from membranes, this enzyme has a theoretical inflammatory potential. Herniated lumbar discs have a higher level of phospholipase A2 than do normal discs. The purpose of this study was to evaluate the inflammatory capability of purified human disc phospholipase A2. Phospholipase A2 extracted and purified from human disc was found to be inflammatory. Its inflammatory capability was directly related to its ability to function enzymatically. When the enzyme was treated with parabromophenacyl bromide (p-BPB) to specifically alkylate the active site histidine and block catalytic activity, the ability of the modified protein to produce edema was markedly reduced. Careful regulation of the activity of this enzyme is important in vivo because its inflammatory potential could result in disc degeneration and nerve injury.

Response to steroid and duration of radicular pain as predictors of surgical outcome.

Prolonged structural compromise of spinal nerve roots can lead to chronic changes that surgical decompression might not be able to reverse. In this study, it was hypothesized that if there were a reversible structural pain component, a steroid injected into the patient's symptomatic nerve root should provide temporary pain relief and that these patients should have a favorable surgical outcome. It also was hypothesized that duration of radicular symptoms would correlate inversely with surgical outcome. For postoperative relief of radicular pain, the results showed that patients with pain lasting less than 1 year had a positive surgical result (89%), regardless of response to steroid. Patients with pain lasting more than 1 year and who have had a positive response to steroid injected into the symptomatic nerve root (roots) had a positive surgical outcome of 85%. Patients who did not respond to the steroid and had pain for more than 1 year (95%) generally had a poor surgical outcome. Although the poor outcome in the last group might be explained in some cases by an inadequate structural correction, inadequate stabilization, or functional reasons, the majority of these failures represented irreversible changes in the neural structures.

The value of somatosensory evoked potential testing for upper lumbar radiculopathy. A correlation of electrophysiologic and anatomic data.

Patients with lumbar pain syndromes can present with a complex variety of complaints. Most clinicians focus on the lower lumbar nerve roots, but upper lumbar radicular syndromes can provide an especially difficult diagnostic challenge to the spine specialist requiring a multimodal approach to sort out diagnostic complexities. The purpose of this study was to analyze the correlation of somatosensory evoked potential findings with documented spinal pathology demonstrated on morphologic studies, thereby determining whether somatosensory evoked potential testing has a place in spinal diagnosis. The results of this study demonstrated the correlation of somatosensory evoked potential findings with anatomic abnormalities noted on computed tomographic and magnetic resonance imaging scans and discograms. Somatosensory evoked potential testing is recommended not as an isolated test, but as part of an electrophysiologic battery that would also include conventional electromyography.

The new back school prescription: stabilization training. Part II.

This article describes stabilization concepts and discusses the role of the physician in stabilization training. The goals of sports-specific training programs for rehabilitation of the injured athlete are also discussed.

Common American football injuries.

As many as 1.5 million young men participate in American football in the United States. An estimated 1.2 million football-related injuries are sustained annually. Since the 1970s epidemiological studies have shown that the risk of injury is higher in older athletes and lower in teams with more experienced coaches and more assistant coaches. 51% of injuries occurred at training; contact sessions were 4.7 times more likely to produce injuries than controlled sessions. Injury rates were reduced by wearing shorter cleats and preseason conditioning. Overall, lower extremity injuries accounted for 50% of all injuries (with knee injuries accounting for up to 36%). Upper extremity injuries accounted for 30%. In general, sprains and strains account for 40% of injuries, contusions 25%, fractures 10%, concussions 5% and dislocations 15%. Cervical spine injuries have the potential to be catastrophic, but they declined dramatically in the decade 1975 to 1984, due to the impact of rule changes modifying tackling and blocking techniques and improved fitness, equipment and coaching. Appropriate diagnostic evaluation of cervical injuries is mandatory. The evidence supporting prophylactic knee bracing is not compelling and does not mandate compulsory or routine use. Return to play criteria include: full range of motion; normal strength; normal neurological evaluation; no joint swelling or instability; ability to run and sustain contact without pain; no intake of pain medication; player education about preventive measures and future risks. These criteria should be strictly observed. In addition to ankle and knee rehabilitation, lumbar spine injuries present a challenge for the physician. Repetitive flexion, extension and torsional stresses predispose the lumbar spine to injury. Rehabilitation consists of pain control and training. The training phase aims to eliminate repetitive injuries by minimising stress at the intervertebral joint. Football is a high risk sport. Coaches, players, trainers and physicians must all become aware of the proper means to prevent injuries.

The importance of posterior epidural fat pad in lumbar central canal stenosis.

Ninety-three patients with lumbar central canal stenosis were prospectively evaluated to determine whether the posterior epidural fat was an important component in the pathogenesis of thecal sac compression. Results of this study indicated that, in patients with acquired stenosis secondary to facet arthrosis, posterior compression of the thecal sac by epidural fat was identified. This finding was not observed in patients with stenosis secondary to anterior column pathology or in patients with developmentally large facets.

The sports medicine approach to occupational low back pain.

Absenteeism caused by low back pain costs industry millions of dollars per year. Innovative approaches for the prevention and treatment of low back pain in workers are mandatory. The sports medicine approach for aggressive rehabilitation offers a possible solution.

Physical medicine and rehabilitation: lumbar stabilizing exercises for the nonoperative treatment of disc lesions.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in physical medicine and rehabilitation. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in physical medicine and rehabilitation that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Physical Medicine and Rehabilitation of the California Medical Association, and the summaries were prepared under its direction.

Dynamic muscular stabilization in the nonoperative treatment of lumbar pain syndromes.

The results of a three-year study of patients with herniated nucleus pulposus and radiculopathy are presented. Nonoperative treatment options for these lumbar disorders, ie, an aggressive physical rehabilitation program, pain control methods, exercise training designed to eliminate repetitive intervertebral disc or facet joint injury, and dynamic muscular lumbar stabilization techniques, were utilized. Successful outcomes were achieved in 50 of the 52 (96%) nonoperatively treated patients. A subcategory of patients with extruded nuclear fragments had an 87% success rate. Ninety-two percent of the overall study population was able to return to work.

High levels of inflammatory phospholipase A2 activity in lumbar disc herniations.

Inflammation of neural elements is frequently mentioned clinically in association with lumbar radiculopathy. Mechanical embarrassment of neural elements by definable structural abnormalities is inadequate as a sole explanation of nerve injury in this condition. The purpose of this study was to demonstrate whether an enzymatic marker for inflammation (phospholipase A2) could be identified in human disc samples removed at surgery for radiculopathy due to lumbar disc disease. Samples were assayed for phospholipase A2 activity. The level of activity in the disc samples was compared with values obtained from other human tissues using the same assay. Specific activity (percent hydrolysis radiolabelled substrate) ranged from 238 to 1,014.5 nmol/min/mg. Mean activity for the human disc material was 568.7 nmol/min/mg, compared with 0.006 nmol/min/mg for human PMN, and 12.1 nmol/min/mg for inflammatory human synovial effusion. The pH and cation-related activity were identical to those demonstrated for phospholipase A2 inflammatory conditions. Human lumbar disc phospholipase A2 activity is from 20- to 100,000-fold more active than any other phospholipase A2 that has been described. As the enzyme responsible for the liberation of arachidonic acid from cell membranes, phospholipase A2 is the rate-limiting step in the production of prostaglandins and leukotrienes. These data establish biochemical evidence of inflammation at the site of lumbar disc herniations.

The natural history of lumbar intervertebral disc extrusions treated nonoperatively.

The purpose of this study was to evaluate the natural history of morphologic changes within the lumbar spine in patients who sustained lumbar disc extrusions. All patients in this study were treated nonoperatively for radicular pain and neurologic loss. The following questions were addressed: 1) Does perithecal or perineural fibrosis result when extrusions are not removed surgically, and 2) Do disc extrusions spontaneously resolve, and, if so, how rapidly? The study population consisted of 11 patients with extrusions and radiculopathy. All patients were successfully treated nonoperatively. All had a primary complaint of leg pain and all had positive straight leg raising reproducing their leg pain at less than or equal to 60 degrees. Additionally, 87% had muscle weakness on a neurologic basis in a root level distribution corresponding to the site of disc pathology. Computed tomographic (CT) examinations were obtained on all patients at the inception of treatment. These studies were compared with follow-up MRI studies. The initial CT scans were evaluated for the following criteria: disc size and position, thecal sac effacement, nerve root enlargement or displacement, and evidence of central or intervertebral canal stenosis. In addition to the pathomorphology evaluated on the CT scans, follow-up MRI studies also evaluated disc hydration at the herniated and contiguous levels, and the presence of perithecal or perineural fibrosis. The following grading system was used to evaluate change in fragment size on the follow-up studies: Grade 1-0 to 50% decrease in size; Grade 2-50 to 75% decrease in size; Grade 3-75 to 100% decrease in size.(ABSTRACT TRUNCATED AT 250 WORDS)