Discogenic Pain: Diagnosis and Treatment

Computed Tomog

Guyer RD, Ohnmeiss DD. Lumbar discography. P
Spine Society Diagnostic and Therapeutic Commit

graphy-Discography

Position statement from the North American
ttee. Spine. 1995;20:2048-2059.

Discoge

• Anatomy and path
• Patient evaluation
• Treatment

– Functional restora
– Intradiscal Electro
– Lumbar fusion

enic Pain

hophysiology
n

ation
othermal Therapy (IDET)

Discoge
Acute Phase R

enic Pain:
Rehabilitation

Why Reh

• Absence of symp
normal function

• Prolonged “rest”
• Accelerate restor
• Decrease recurre

duration and inte
• Limit the need fo

habilitate?

ptoms does not imply

is detrimental
ration of function
ence frequency,
ensity
or surgery

Goals of A

Acute Stage

• Education

– Posture and body
mechanics

– Protection of the injured
tissue

• Control pain and reduce
inflammation

• Early mobility to produce
physiologic loading

• Aerobic fitness

Methods to Co
Inflamm

• Activity modificat
• Thermal and elect
• Medication
• Manual therapy
• Traction
• Bracing
• Spinal injection
• Initial exercise

ontrol Pain &
mation

tion
trical modalities

Deleterious Effe

• Decreased muscle strength
• Loss of large muscle

flexibility
• Increased segmental

stiffness
• Impaired cardiovascular

fitness
• Reduced bone density
• Decreased disc nutrition

ects of Inactivity

Medic

• Analgesics
– NSAIDS (mechanism
– Tylenol, Tramadol
– Opioids (time conting

• Anti-inflammatories
– NSAID’s (consider s
– Corticosteroids (cons

• Muscle relaxants
– True persistent muscl
– Most act via central n

cation

m of pain relief unclear)
gent use most effective)
side effects)
sider side effects)
le spasm unusual
nervous system

Trac

• Types: inversion, pelvic
belts

• Benefits

• Myofascial stretch low
back and hip girdle

• Joint distraction
• Neural canal

decompression

• Intervertebral traction
requires at least 25 - 50%
of body weight

• Temporary measure

ction

Brac

• Soft corset (±metal stays)
as limited measure

– Comfort and warmth
– Proprioceptive feedback
– Body mechanics reminder

• Rigid brace

– Symptomatic instability o
hypermobility

– Acute spondylolysis
(comfort vs. healing)

– Immobilization probably n
effective for L5-S1 segme

cing

)

r
or

not
ent

Intradiscal Electr
(ID

•R
le
fo
sy
p

•U
in
to
c

rothermal Therapy
DET)

Recently introduced as a
ess invasive treatment
or patients with
ymptomatic discogenic
pain (Smith & Nephew)

Uses a navigable,
nsulated resistive heater
o treat intervertebral disc
collagen

Intradiscal Electr
(ID

Outco

• No ra

• No c
wors
Saal JA, Saal JS. Spine 2000; cond
repor
25:2622-2627. • studi

Karasek M, Bogduk N. Spine >50%
of tre
2000; 25:2601-2607.
– SF
Saal JA, Saal JS. Spine
2002;27:966-974. –O

Wetzel FT, et al. [Review] Spine
2002; 27:2621-2626.

rothermal Therapy
DET):

omes:

andomized trials prior to release
complications, adverse events, or
sening of the baseline clinical
dition at one-year follow-up
rted after IDET (2 prospective
ies in a total of 115 patients)
% improvement well over half
eated patients

F-36: Physical Function, Pain
Oswestry Disability Scores

Intradiscal Electr
(IDE

Outcomes:

• Randomized, sham-c
• 1,360 patients screen

eligible for enrollme
• 37 IDET/27 sham
• Strict inclusion criter

outcome measures (S

Pauza K

othermal Therapy
ET):

controlled trial
ned to identify 64
ent

ria/standardized
SF-36 and Oswestry)

KJ. The Spine Journal 2004; 4:27-35.

Intradiscal Electr
(IDE

Outc

• Patients improved af
(SF-36 Physical Fxn

• NNT = 5 to attain 75
• 40% achieved >50%
• 50% experienced no

Pauza K

othermal Therapy
ET):

comes

fter both IDET and sham
n, Oswestry, & VAS)
5% pain improvement
% improvement
o appreciable benefit

KJ. The Spine Journal 2004; 4:27-35.

Intradiscal Electro
(IDET): Futu

A Randomized Clinica
Electrothermal Therapy

Spinal Fusion for Tr
Discogenic L

James P. Rat
Robert A. Mo

Jerry M. Ta

othermal Therapy
ure Directions

al Trial of Intradiscal
y (IDET) versus Anterior
reatment of Chronic,
Low Back Pain

thmell, MD
onsey, MD
arver, MD





IDET v

Rathmell

v. ALIF

l JP, Monsey RB. IDET v. Anterior Lumbar
Interbody Fusion. JUR 2003;0:00-00.

IDE

Conclu
• Nonspecific factors ass

procedure account for a
of IDET
• IDET appears to provid
small proportion of stri
with low back pain

ET

usions
sociated with the
a portion of the efficacy

de worthwhile relief in a
ictly defined patients

Minimally Invas

Nucleoplasty
•Prospective observational study
67 patients with DDD with/witho
contained disc protrusions
•Sustained improvements in pain
reduction and improved function
>60% of patients at 12 months af
treatment

Singh V. Pain Physician 2002;5:250-2

sive Discectomy

y of
out
n
n in
fter

259.

Minimally Invas

sive Discectomy

Minimally Invas

sive Discectomy

Anterior Interbod

A 50 year old
man

following
anterior

interbody
fusion using

titanium
interbody

cages.

dy Lumbar Fusion

Lumbar Fusion: Ped

A 56 year-ol
man followin

lumba
laminectom
and posterio

fusion wit
pedicle screw
rod construct

dicle Instrumentation

ld
ng
ar
my
or
th
w-
t.

Discoge

Conclu

• A common cause of axial
• Pain is usually self limited
• IDET has shown limited e
• Disc replacement is evolvi
• Lumbar interbody fusion r

therapy for persistent pain

enic Pain

usions

low back pain
d
efficacy in selected patients
ing
remains the only established
n