A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography A Prospective Study of Centralization of Lumbar and Referred Pain: A Predictor of Symptomatic Discs and Anular Competence Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? Correlation of clinical examination characteristics with three sources of chronic low back pain. Endplate Degeneration Observed on Magnetic Resonance Imaging of the Lumbar Spine: Correlation with Pain Provocation and Disc Changes Observed on Computed Tomography Diskography Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Results of Surgery for Discogenic Low Back Pain: A Randomized Study Using Discography Versus Discoblock for Diagnosis Disc Stimulation and Patterns of Referred Pain Provocative discography in volunteer subjects with mild persistent low back pain. The Relative Contributions of the Disc and Zygapophyseal Joint in Chronic Low Back Pain Provocative cervical discography symptom mapping. A Randomized, Double-Blind, Controlled Trial: Intradiscal Electrothermal Therapy Versus Placebo for the Treatment of Chronic Discogenic Low Back Pain Prospective clinical study on natural history of discogenic low back pain at 4 years of follow-up. A randomized, double-blind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: results of 2-year follow-up. Randomized Controlled Trial of Percutaneous Intradiscal Radiofrequency Thermocoagulation for Chronic Discogenic Back Pain: Lack of Effect From a 90-Second 70 C Lesion Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source Disc height and motion patterns in the lumbar spine in patients operated with total disc replacement or fusion for discogenic back pain. Results from a randomized controlled trial.
Study Design . This is a prospect i ve study of the validity of a positive test result in provocative lumbar discography for the diagnosis of “ discogenic pain . ” Objective . To investigate the hypothesis that provocative discography by strict criteria accurately identifies a low back pain illness due to a primary disc lesion . Summary and Background Data . According to the Sackett and Haynes criteria for establishing diagnostic test validity , no test without a gold st and ard external st and ard can be meaningfully applied . Provocative discography as a test for determining “ discogenic pain ” has , to date , not been compared against a gold st and ard . Absent a gold st and ard reference , there can be no validity assessment or systematic improvement of test accuracy . This is the first study to apply an external gold st and ard evaluation of the diagnostic validity of discography in any manner . Methods . Over a 5-year period using a strict enrollment protocol , 32 patients with low back pain and a positive single-level low-pressure provocative discogram , underwent spinal fusion . Subjects with known patient selection comorbidities were excluded . Generic surgical limitations /morbidity were controlled by comparison to the clinical outcomes of a strictly-matched cohort of 34 patients having a well-accepted single-level lumbar pathology ( unstable spondylolisthesis ) . Treatment success was compared between groups . Results . In the control-spondylolisthesis group , 23 of 32 patients ( 72 % ) met the highly effective success criteria compared with 8 of 30 in the presumed discogenic pain cohort ( 27 % ) . The proportion of patients who met the “ minimal acceptable outcome ” was 29 of 32 ( 91 % ) in the spondylolisthesis group and 13 of 30 ( 43 % ) in the presumed discogenic pain group . Adjusting for surgical morbidity and dropout failure , by either criteria of success , the best-case positive predictive value of discography was calculated to be 50 % to 60 % . Conclusions . Positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness in this first study comparing discography results to a gold st and ard Study Design . The presence or absence of rapidly central izing , peripheralizing , or abolishing low  back and radiating pain , as identified during a McKenzie mechanical lumbar assessment of patients with chronic lumbar pain , was compared prospect ively with discographic pain provocation and anular competency . Objectives . To evaluate any relation between the responses of central ization and peripheralization with discographic findings . Summary of Background Data . Central ization of referred pain has been reported as a very common occurrence during McKenzie assessment and treatment . Patients whose pain central izes have been shown to achieve superior treatment outcomes . A dynamic internal disc model has been hypothesized as an underlying mechanism for central ization that has not been studied previously . Methods . Patients with chronically disabling low back pain who were referred for discography underwent preliminary blinded McKenzie clinical assessment and were categorized into three groups by their pain response . Patterns , or lack thereof , of pain response were then compared with blinded discographic pain provocation and anular findings . Results . During the McKenzie assessment , the referred pain of 50 % central ized with 74 % having positive discograms , of which 91 % had an intact anulus . The pain of 25 % peripheralized only ( would not central ize ) ; 69 % of these had positive discograms , but only 54 % had an intact anulus . The distal pain of 25 % did not respond at all , and only 12.5 % of these had positive discograms . Conclusion . The McKenzie assessment process reliably differentiated discogenic from nondiscogenic pain ( P < 0.001 ) as well as competent from an incompetent anulus ( P < 0.042 ) in symptomatic discs and was superior to magnetic resonance imaging in distinguishing painful from nonpainful discs BACKGROUND CONTEXT Lumbar discography has been widely used for evaluating discogenic low back pain ( LBP ) . Comparison of pain responses from suspected symptomatic discs with pain responses from asymptomatic negative discs is routine . However , the ability of discography to distinguish asymptomatic morphologically abnormal discs from those that are symptomatic has been understudied . In addition , the discographic characteristics of negative discs in patients with chronic discogenic LBP have not been reported . Criteria for negative morphologically abnormal discs may be valuable for excluding discs from further treatment and examination . PURPOSE To determine if discography can distinguish asymptomatic discs among morphologically abnormal discs in patients with suspected chronic discogenic LBP and establish the st and ard characteristics of negative discs . STUDY DESIGN / SETTING Prospect i ve , experimental with control group . PATIENT SAMPLE Fifty-five discs from a control group of 16 healthy volunteers without current back pain ( 11 men , 5 women , 32 - 61 years of age , mean age : 47 years ) and 282 discs from a patient group of 90 LBP patients ( 59 men , 31 women , 20 - 70 years of age , mean age : 44.7 years ) were recruited . METHODS Discography was performed using a pressure-controlled manometric technique with an injection rate of 0.05 mL/s and a 3.5 mL restricted total volume . Concordance was rated as none/unfamiliar , or familiar . Pain was rated via a 0 - 10 numerical rating scale ( NRS ) . The pressure and volume at which pain was evoked and NRS pain responses at 15 , 30 , and 50 psi were recorded . Annular disruption grade was rated during the procedure by computed tomography discography and fluoroscopic imaging . Negative discogram required no pain described by the participant as " familiar , " with no pain responses > or=6/10 NRS at pressures < or=50 psi above opening pressure and < or=3.5 mL total injected volume . Patient discs were partitioned into two subgroups based on discographic findings : Neg-D ( negative discs ) and Pos-D ( positive discs ) . Only discs with Grade 3 annular tears ( Dallas Discogram Scale ) were included in the study . RESULTS Among 55 asymptomatic control group discs , 32 ( 58.2 % ) exhibited Grade 3 annular tear . All discs in the asymptomatic control group satisfied negative response criteria . Among 282 patient group discs , 199 ( 70.6 % ) exhibited Grade 3 annular tear . Of 199 discs with Grade 3 annular tears , 104 ( 52.3 % ) satisfied negative response criteria and were categorized as the Neg-D group . The other 95 discs were categorized as a Pos-D group . Patients showed significantly lower pain tolerance relative to control subjects ( p<.05 ) . The control and Neg-D groups showed similar pressures and volumes at which pain was initially evoked . Mean control group pain scores were 0.47 NRS at 15 psi and 1.58 NRS at 50 psi . Mean Neg-D group pain scores were 0.11 NRS at 15 psi and 1.1 NRS at 50 psi . Discographic findings for the Pos-D group were significantly different from those of the control and Neg-D groups ( p<.001 ) . CONCLUSIONS Pain tolerance was significantly lower in patients relative to asymptomatic subjects . Negative patient discs and asymptomatic subject discs showed similar characteristics . Pressure-controlled manometric discography using strict criteria may distinguish asymptomatic discs among morphologically abnormal discs with Grade 3 annular tears in patients with suspected chronic discogenic LBP BACKGROUND CONTEXT Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac ( SI ) joint sources of pain . No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated . PURPOSE To identify significant components of a clinical examination that are associated with symptomatic lumbar discs , zygapophysial joints and SI joints . STUDY DESIGN A prospect i ve , criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics . PATIENT SAMPLE The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections .  OUTCOME MEASURES Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections . Statistical analysis included chi-squared test for independence , phi and odds ratios with confidence intervals . METHOD Patients received blinded clinical examinations by physical therapists , and diagnostic injections were used as the criterion st and ard . RESULTS Significant relationships were found between discogenic pain and central ization of pain during repeated movement testing , and pain when rising from sitting . Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting . Sacroiliac joint pain was related to three or more positive pain provocation tests , pain when rising from sitting , unilateral pain and absence of lumbar pain . CONCLUSIONS Significant correlations exist between clinical examination findings and symptomatic lumbar discs , zygapophysial and SI joints . The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests , central ization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints Study Design . One hundred and three lumbar intervertebral discs ( L3/4-L5/S1 ) of 36 patients with low back pain were examined with computed tomography ( CT ) diskography and magnetic resonance imaging ( MRI ) . Objectives . To determine whether lumbar endplate degeneration correlates with the degree of disc degeneration or disc rupture and to determine if there is an association between pain provocation during diskography and lumbar endplate degeneration . Summary of Background Data . There have been numerous attempts to explain the pathogenesis of pain provocation during diskography , but the possibility of endplate degeneration as a source of pain has not been widely assessed . Methods . One hundred and three lumbar intervertebral discs ( 36 L3/4 , 36 L4/5 , and 31 L5/S1 intervertebral discs ) of 36 patients were examined . On the basis of MRI , the intervertebral discs were divided into four categories based on the degree of endplate degeneration . Based on pain provocation on diskography , the intervertebral discs were divided into three categories : no pain , indifferent/untypical pain , and familiar/typical pain . Based on disc degeneration and disc rupture , the intervertebral discs were divided into four categories in accordance with the Dallas Discogram Description : Grade s 0–3 of both degeneration and rupture . Results . There was a positive correlation between endplate degeneration and disc degeneration and a positive correlation between disc rupture and pain provocation , but there was no association between endplate degeneration and disc rupture and no correlation between endplate degeneration and pain provocation on diskography . Conclusions . This study showed a stronger association between endplate degeneration and disc degeneration than between endplate degeneration and disc rupture . The results indicate that the contrast injection during diskography reflects mainly pain of discogenic origin , whereas the possible pain associated with endplate damage can not be depicted by CT diskography BACKGROUND CONTEXT The " central ization phenomenon " ( CP ) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing ( a McKenzie evaluation ) . A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain . PURPOSE Estimation of the diagnostic predictive power of central ization and the influence of disability and patient distress on diagnostic performance , using provocation discography as a criterion st and ard for diagnosis , in chronic low back pain patients . STUDY DESIGN / SETTING This study was a prospect i ve , blinded , concurrent , reference st and ard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain . PATIENT SAMPLE Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures . Patients were typically disabled and displayed high levels of psychosocial distress . The sample included patients with previous lumbar surgery , and most had unsuccessful conservative therapies previously . OUTCOME MEASURES DIAGNOSIS results of provocation discography . INDEX TEST The CP . Psychometric evaluation : Rol and -Morris , Zung , Modified Somatic Perception question naires , Distress Risk Assessment Method , and 100-mm visual analog scales for pain intensity . METHODS Patients received a single physical therapy examination , followed by lumbar provocation discography .  Sensitivity , specificity , and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures . RESULTS A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography .  Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis . Disability and pain intensity ratings were high , and distress was common . Sensitivity , specificity , and positive likelihood ratios for central ization observed during repeated movement testing for pain distribution and intensity changes were 40 % , 94 % , and 6.9 respectively . In the presence of severe disability , sensitivity , specificity , and positive likelihood ratios were 46 % , 80 % , 3.2 and for distress , 45 % , 89 % , 4.1 . In the subgroups with moderate , minimal , or no disability , sensitivity and specificity were 37 % , 100 % and for no or minimal distress 35 % , 100 % . CONCLUSIONS Central ization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress Study Design . R and omized , controlled study . Objective . To evaluate the diagnosis of discogenic low back pain ( LBP ) with discography and discoblock . Summary of Background Data . Discogenic LBP is usually diagnosed by magnetic resonance imaging and discography . However , the reliability of discography is controversial . Previously , we reported the usefulness of discoblock with bupivacaine for diagnosis , and discoblock improved the results of anterior interbody fusion surgery . However , that study was not a r and omized , controlled study . Therefore , the purpose of the current study was to compare the results of surgery after diagnosis of LBP by discography and discoblock . Methods . Patients ( n = 42 ) with severe LBP showing L4–L5 or L5–S1 disc degeneration on magnetic resonance imaging were evaluated by discography ( 1.5 mL of contrast medium ) or discoblock ( intradisc injection of 0.75 mL of 0.5 % bupivacaine ) . We r and omized the patients in turn . Anterior discectomy and interbody fusion were performed in patients who responded to the diagnostic procedures . The visual analogue scale score ( 0 , no pain ; 100 , worst pain ) , Japanese Orthopedic Association Score ( 0 , worst pain ; 3 , no pain ) , Oswestry Disability Index , and patient satisfaction before and 3 years after surgery were recorded and compared between groups . Results . Twelve patients did not show pain provocation by discography or pain relief by discoblock and were excluded . Fifteen patients who showed pain provocation by  discography and 15 patients who experienced pain relief with discoblock were evaluated . Rates of improvement in the visual analogue scale score , Japanese Orthopedic Association Score , and Oswestry Disability Index score in the discoblock group were significantly higher than those in the discography group ( P < 0.05 ) from baseline to 3 years after surgery . Three patients were dissatisfied with surgery after discography compared with one patient after discoblock . Conclusion . Pain relief after injection of a small amount of bupivacaine into the painful disc was a useful tool for the diagnosis of discogenic LBP compared with discography Study Design . Prospect i ve , within-subjects , observational experimental design . Objectives . To determine the pattern of pain response to noxious stimulation of the intervertebral disc .  Summary of Background Data . Experimental studies have demonstrated that noxious stimulation of interspinous ligaments , facet joints , and paravertebral muscles causes referred pain into the extremity , with the distal extent of radiation dependent on the intensity of stimulation . Analogous studies have not been performed on the lumbar intervertebral disc . Methods . A total of 25 consecutive patients meeting inclusion criteria completed a  pain diagram  before undergoing the intradiscal electrothermal annuloplasty procedure .  The location , intensity , and familiarity of any pain provoked during disc heating were correlated with presenting symptoms and duration of heating . Results . During disc heating , 68 % of patients reported exact reproduction of their presenting pain , in both pain quality and location . None of the patients experienced unfamiliar pain during the procedure . The pattern of pain reproduction was consistent ; pain originated proximally and progressed distally as stimulus intensity increased . Conclusion . Noxious stimulation of the intervertebral disc may result in low back and referred extremity in patients presenting with these symptoms . The distal extent of pain produced depends on the intensity of stimulation . Disc stimulation may reproduce pain that extends to below the knee BACKGROUND CONTEXT Whether discographic injections would be positive in subjects with benign persistent " backache " who are not seeking treatment is unknown . This information is important , because benign backache undoubtedly co-exists in patients with chronic low back pain ( CLBP ) illness that is not discogenicin origin . If these subjects had a high rate of positive discography , the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness . Conversely , if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections , the basic tenet of discographic diagnosis would be strengthened . PURPOSE To compare , using a strict experimental design , the relative pain and concordancy response to provocative discography in subjects with clinical ly insignificant " backache " and clinical subjects with CLBP illness considering surgical treatment . STUDY DESIGN Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain ( CLBP ) illness . PATIENT SAMPLE Twenty-five subjects with mild persistent low back pain ( LBP ) were recruited for an experimental discography study . Subjects were recruited from a clinical study of patients having had cervical spine surgery . Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP , be taking no medications for backache , have no activity restrictions because of LBP , and have normal psychometric scores . To more closely approximate the pain behavior in CLBP illness , 50 % ( 12 ) of the " backache " group were recruited with a chronic painful condition ( neck/shoulder ) unrelated to the low back . CLBP subjects , patients coming to discography for consideration of surgical treatment , were used as control subjects . OUTCOME MEASURES Results of discography were determined using the criteria of Walsh et al. : pain response of 3 or greater , two or more pain behaviors , a negative " control " discographic injection , and a similar or exact concordancy rating . METHODS Discography was performed on experimental subjects and control patients . Experienced raters , who were blinded to control versus experimental status of the subjects , scored the magnetic resonance image , discogram , psychometric tests and discography videotapes of the subjects ' pain behavior . RESULTS Thirteen of 25 volunteer subjects had pain rated as " bad " or worse with disc injection . There were 12 painful and fully concordant disc injections in 9 of these 25 " backache " subjects ( 36 % ) . These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain . All positive discs had annular disruption to or through the outer annulus . Of the 9 subjects with positive discograms , 3 had no chronic pain states and 6 did . All subjects with positive injections had negative control discs . In comparison , in 52 subjects with CLBP illness 38 ( 73 % ) had at least one positive disc injection . CONCLUSIONS In a group of volunteer subjects with persistent " backache , " 36 % were found to have significant pain on disc injection , which is reported to be concordant with their usual pain . The presence of positive concordant pain responses and negative control discs in 33 % of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinical ly relevant spinal pathology Study Design . A prospect i ve cross-sectional analytic approach was taken . Objectives . This study sought to determine the relative contribution of the disc and the zygapophyseal Joint as a pain source in patients with chronic low back pain . Summary of Background Data . Previous studies have employed either zygapophyseal joint blocks or discography , but in no studies have both procedures been performed . Methods . Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints . Results . Thirty-six patients ( 39 % ) had at least one positive discogram as defined by exact pain reproduction , an abnormal image , and a negative control . Eight patients responded to both a screening zygapophyseal joint block using lignocaine and confimatory block using bupivacaine . Only three patients had both a positive discogram and a symptomatic zygapophyseal joint . Conclusions . In patients with chronic low back pain , the combination of discogenic pain and zygapophyseal joint pain is uncommon BACKGROUND CONTEXT In a small prospect i ve study assessing 10 symptomatic and 10 asymptomatic subjects , Schellhas et al. compared cervical discography to magnetic resonance imaging . Within that study he reported on the distribution of pain for the C3-C4 to C6-C7 levels . Four years later , Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2-C3 to C7-T1 in 173 patients . To date , no large prospect i ve study defining pain referral patterns for each cervical disc has been performed . PURPOSE To conduct a prospect i ve visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography .  STUDY DESIGN / SETTING Prospect i ve multicenter descriptive study . METHODS Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed . If concordant pain was reproduced in a morphologically abnormal disc , the subject immediately completed a pain diagram . An independent observer interviewed the subject and recorded the location of provoked symptoms . Visual data were compiled using a body sector bit map , which consisted of 48 clinical ly relevant body regions . Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated . RESULTS A total of 101  symptom provocation maps  were recorded during cervical discography on 41 subjects . There were 10 at C2-C3 , 19 at C3-C4 , 27 at C4-C5 , 27 at C5-C6 , 16 at C6-C7 and 2 at C7-T1 . Predominantly unilateral symptoms were provoked just as often as bilateral symptoms . The C2-C3 disc referred pain to the neck , subocciput and face . The C3-C4 disc referred pain to the neck , subocciput , trapezius , anterior neck , face , shoulder , interscapular and limb . The C4-C5 disc referred pain to the neck , shoulder , interscapular , trapezius , extremity , face , chest and subocciput . The C5-C6 disc referred pain to the neck , trapezius , interscapular , suboccipital , anterior neck , chest and face . The C6-C7 disc referred pain to the neck , interscapular , trapezius , shoulder , extremity and subocciput . At C7-T1 we produced neck and interscapular pain . Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated . CONCLUSIONS In conclusion , these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms . The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess . With these data , the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs Study Design . A prospect i ve , r and omized , double-blind , placebo-controlled trial of intradiscal electrothermal therapy ( IDET ) for the treatment of chronic discogenic low back pain ( CDLBP ) . Objectives . To test the safety and efficacy of IDET compared with a sham treatment ( placebo ) . Summary of Background Data . In North America alone , more than 40,000 intradiscal catheters have been used to treat CDLBP . The evidence for efficacy of IDET is weak coming from retrospective and prospect i ve cohort studies providing only Class II and Class III evidence . There is one study published with Class I evidence . This demonstrates statistically significant improvements following IDET ; however , the clinical significance of these improvements is question able . Methods . Patients with CDLBP who failed to improve following conservative therapy were considered for this study . Inclusion criteria included the presence of one- or two-level symptomatic disc degeneration with posterior or posterolateral anular tears as determined by provocative computed tomography ( CT ) discography . Patients were excluded if there was greater than 50 % loss of disc height or previous spinal surgery . Fifty-seven patients were r and omized with a 2:1 ratio : 38 to IDET and 19 to sham procedure ( placebo ) . In all cases , the IDET catheter was positioned to cover at least 75 % of the annular tear as defined by the CT discography . An independent technician connected the catheter to the generator and then either delivered electrothermal energy ( active group ) or did not ( sham group ) . Surgeon , patient , and independent outcome assessor were all blinded to the treatment . All patients followed a st and ard postprocedural rehabilitation program . Independent statistical analysis was performed . Outcome Measures . Low Back Outcome Score ( LBOS ) , Oswestry Disability Index ( ODI ) , Short Form 36 question naire ( SF-36 ) , Zung Depression Index ( ZDI ) , and Modified Somatic Perceptions Question naire ( MSPQ ) were measured at baseline and 6 months . Successful outcome was defined as : no neurologic deficit , improvement in LBOS of greater then 7 points , and improvement in SF-36 subsets ( physical function and bodily pain ) of greater than 1 st and ard deviation . Results . Baseline demographic data , initial LBOS , ODI , SF-36 , ZDI , and MSPQ were similar for both groups . No neurologic deficits occurred . No subject in either arm showed improvement of greater than 7 points in LBOS or greater than 1 st and ard deviation in the specified domains of the SF-36 . Mean ODI was 41.42 at baseline and 39.77 at 6 months for the IDET group , compared with 40.74 at baseline and 41.58 at 6 months for the placebo group . There was no significant change in ZDI or MSPQ scores for either group . Conclusions . The IDET procedure appeared safe with no permanent complications . No subject in either arm met criteria for successful outcome . Further detailed analyses showed no significant change in outcome measures in either group at 6 months . This study demonstrates no significant benefit from IDET over placebo BACKGROUND To accurately assess the effect of any therapy for treating discogenic low back pain , the natural history of such pain should be known beforeh and . However , until now , no pathological characteristic could be used to predict the disease course of low back pain . OBJECTIVE To better instruct the clinical treatment of discogenic low back pain , a prospect i ve clinical study was performed to observe the natural history of the disease . STUDY DESIGN A prospect i ve clinical study during a 4-year follow-up period . SETTING The study was performed at a spinal center in China . METHODS A total of 279 patients with chronic low back pain were included from June 2006 through October 2007 . Using discography , 156 patients ( 56 % ) were diagnosed to have discogenic back pain . A 101-point numerical rating scale ( NRS ) was used to assess the back pain symptoms and the Oswestry Disability Index ( ODI ) was used to assess lumbar function . RESULTS Of the 156 patients , 131 ( 84 % ) completed the study at 4-year follow-up . At the end of follow-up , 17 patients ( 13.0 % ) had their low back pain symptoms alleviated and lumbar function improved ; 10 patients ( 7.6 % ) were slightly improved ; 16 patients ( 12.2 % ) had their symptoms aggravated ; and 88 patients ( 67.2 % ) experienced the same pain and disability as before . Although the average NRS and ODI scores obtained during the 4-year follow-up study gradually decreased , statistical significance s were found in such changes ( P < 0.05 , and P < 0.05 , respectively ) ; however , the improvement rates of both pain ( 7.6 % ) and disability ( 5.2 % ) were very low . LIMITATIONS The shortcoming of this study is its relatively small sample size . CONCLUSION The present study indicated that the natural history of discogenic low back pain was chronic but persistent , and that the pain and disability in most patients did not improve over time BACKGROUND Chronic low back with or without lower extremity pain is extremely common , expensive , and disabling . However , all modalities of treatments are directed towards disc herniation which is responsible for a very small proportion of the patients . Thus , chronic low back pain without disc herniation is common . Multiple modalities of treatments are utilized in managing axial or discogenic pain including surgery and epidural injections including surgery , intradiscal therapies , and epidural injections . However , there is continued debate on the effectiveness , indications , and medical necessity of all modalities treatments in managing axial or discogenic pain in the lumbar spine . STUDY DESIGN A r and omized , double-blind , active control trial . SETTING A private practice , specialty referral , interventional pain management practice in the United States . OBJECTIVES To evaluate the ability to assess the effectiveness of lumbar interlaminar epidural injections in managing chronic axial or discogenic low back pain with epidural injections of local anesthetic with or without steroids . METHODS In this study , a total of 120 patients were r and omly allocated to one of the 2 groups receiving either local anesthetic alone or local anesthetic with steroids with 60 patients in each group . The primary outcome measure was at least 50 % improvement in the numeric rating scale ( NRS ) and Oswestry Disability Index ( ODI ) . Outcomes were assessed at 3 , 6 , 12 , 18 , and 24 months post treatment . RESULTS Significant pain relief and functional status improvement defined as at least 50 % or more reduction in scores from baseline were observed in 72 % of patients receiving local anesthetic alone and 67 % of the patients receiving local anesthetic with steroids .  Opioid intake was reduced from baseline in each group for 2 years . LIMITATIONS The results of the study are limited by the lack of a placebo group . CONCLUSION Lumbar interlaminar epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain , disc herniation , and /or radiculitis . TRIAL REGISTRATION NCT00681447 Study Design . A prospect i ve double-blind r and omized trial in 28 patients . Objectives . To assess the clinical effect of percutaneous intradiscal radiofrequency thermocoagulation for reducing pain , functional disability , and physical impairment in patients with chronic discogenic low back pain . Summary of Background Data . Chronic discogenic low back pain is a challenging problem in western countries . A treatment option is radiofrequency heating of the affected disc . Its clinical efficacy has never been formally tested in a controlled trial . Methods . Twenty-eight patients with a history of at least 1 year of chronic low back pain were selected on the basis of a diagnostic anesthetization of the lower intervertebral discs . Only patients with one putative painful level were selected and r and omly assigned to one of two treatment groups . Each patient in the radiofrequency treatment group ( n = 13 ) received a 90-second 70 C lesion of the intervertebral disc . Patients in the control group ( n = 15 ) underwent the same procedure , but without use of radiofrequency current . Both the treating physician and the patients were blinded to the group assignment . Before treatment , physical impairment , rating of pain , the degree of disability , and quality of life were assessed by a blinded investigator . Results . Eight weeks after treatment , there was one success in the radiofrequency group ( n = 13 ) and two in the control group ( n = 15 ) . The adjusted and unadjusted odds ratio was 0.5 and 1.1 , respectively ( not significant ) . Also , visual analog scores for pain , global perceived effect , and the Oswestry disability scale showed no differences between the two groups . Conclusions . Percutaneous intradiscal radiofrequency thermocoagulation ( 90 seconds , 70 C ) is not effective in reducing chronic discogenic low back pain Abstract Disagreement still exists in the literature as to the significance of the high-intensity zone ( HIZ ) demonstrated on magnetic resonance imaging ( MRI ) as a potential pain ¶indicator in patients with low back pain . A prospect i ve blind study was therefore conducted to evaluate the lumbar disc high-intensity zone with the pain provocation response of lumbar discography . Consecutive patients with low back pain unresponsive to conservative treatment and being considered for spinal fusion were subjected to MRI followed by lumbar discography as a pre-operative assessment . The discographer was blinded to the results of the MRI scans . We used the chi-squared test to analyse our results . Ninety-two HIZs were identified in 73 patients , mainly occurring at L4/5 ( 48 % ) and L5/S1 ( 35 % ) . Significant correlation was found between abnormal disc morphology and the HIZ ( P < 0.001 ) . In morphologically abnormal discs ( grade s 3 , 4 and 5 ) , there was a significant correlation between the HIZ and exact or similar pain reproduction ( P < 0.001 ) . The sensitivity , specificity and positive predictive value for pain reproduction were high , at 81 % , 79 % and 87 % respectively . The nature of the HIZ remains unknown , but it may represent an area of secondary inflammation as a result of an annular tear . We conclude from our study that the lumbar disc HIZ observed on MRI in patients with low back pain is likely to represent painful internal disc disruption BACKGROUND CONTEXT Fusion is considered the " gold st and ard " in surgical treatment of degenerated disc disease ; the intended postoperative goal is absence of mobility , but treatment may induce degeneration in adjacent segments . Total disc replacement ( TDR ) aims to restore and maintain mobility by replacing a painful disc . Little is known about the degree and quality of mobility in artificial discs in vivo and whether maintained mobility reduces the stress on adjacent segments that is believed to occur after fusion . PURPOSE To see if surgical goals for respective treatments had been reached , if clinical outcome was related to this , and if differences in disc height at treated segments and adjacent segment motion patterns between groups occurred . STUDY DESIGN Comparison of X-ray measurements in a r and omized controlled trial between instrumented posterior fusion and TDR  for chronic low back pain ( CLBP ) assumed to be discogenic . Results were compared with clinical outcome . PATIENT SAMPLE The material consisted of 152 patients suffering from CLBP assumed to be discogenic . Seventy-two patients were treated with fusion and 80 with TDR . OUTCOME MEASURES Results of X-ray measurements were compared between groups and related to self-reported clinical results regarding back pain and disability . METHODS Flexion-extension X-rays were analyzed preoperatively and 2 years postoperatively using distortion-compensated Roentgen analysis ( DCRA ) at treated and adjacent levels , and mobility after fusion and TDR was estimated . Changes in disc height and range of motion ( ROM ) respective translation in adjacent segments were compared between groups . Results of DCRA measurements were also compared with the clinical outcome . RESULTS Preoperative flexion-extension ROM was similar between the fusion and TDR groups , and preoperative disc heights of segments to be treated were between one and two st and ard deviation less than that previously established in a normative data base . Seventy percent of fused patients had no mobility , whereas 85 % of TDR patients were mobile . Fulfillment of surgical goals was correlated to neither back pain nor disability . Fused segments were lower and TDR segments were higher than normative values postoperatively . There were also significant differences at adjacent segments , there being more translation and flexion-extension in the fusion group than in the TDR group . CONCLUSIONS This very accurate X-ray method ( DCRA ) indicates that surgical goals were reached in most patients . This , however , was not correlated to clinical outcome . Differences between the groups in postoperative disc height at treated segments , respective ROM , and translation at adjacent segments did not affect the clinical outcome after 2 years
RESULTS The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain .
Our findings show that suspected discogenic pain , despite its extensive affirmation in the literature and enormous re sources regularly devoted to it , currently lacks clear diagnostic criteria and uniform treatment or terminology
BACKGROUND CONTEXT Pain innate to intervertebral disc , often referred to as discogenic pain , is suspected by some authors to be the major source of chronic low back and neck pain .
Current management of suspected discogenic pain lacks st and ardized diagnosis , treatment , and terminology .
PURPOSE In an attempt to determine whether patterns existed that may facilitate st and ardization of care , we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain .