|Year : 2019 | Volume
| Issue : 3 | Page : 657-669
Current concepts in intradiscal percutaneous minimally invasive procedures for chronic low back pain
Ioannis Gelalis, Ioannis Gkiatas, Antonios Spiliotis, Dimitrios Papadopoulos, Emilios Pakos, Marios Vekris, Anastasios Korompilias
Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece
|Date of Web Publication||2-Aug-2019|
Department of Orthopaedic Surgery, University of Ioannina, 45500, Ioannina
Source of Support: None, Conflict of Interest: None
Study Design: A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted. Objective: The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures. Materials and Methods: English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included. Results: Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients. Conclusions: These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.
Keywords: Annular tears, chronic low back pain, disc herniation, discogenic pain, intradiscal minimally invasive interventions
|How to cite this article:|
Gelalis I, Gkiatas I, Spiliotis A, Papadopoulos D, Pakos E, Vekris M, Korompilias A. Current concepts in intradiscal percutaneous minimally invasive procedures for chronic low back pain. Asian J Neurosurg 2019;14:657-69
|How to cite this URL:|
Gelalis I, Gkiatas I, Spiliotis A, Papadopoulos D, Pakos E, Vekris M, Korompilias A. Current concepts in intradiscal percutaneous minimally invasive procedures for chronic low back pain. Asian J Neurosurg [serial online] 2019 [cited 2020 Jan 27];14:657-69. Available from: http://www.asianjns.org/text.asp?2019/14/3/657/230994
| Introduction|| |
Low back pain (LBP) is related to disability, work absence, and extensive costs for the health system in societies.,, Point prevalence of LBP ranges from 12% to 33%, 1-year prevalence of LBP ranges from 22% to 65%, and the lifetime prevalence of LBP is up to 84%.,,, The classification of LBP is based on the duration of the symptoms. It is defined as acute when it persists for <6 weeks, subacute between 6 weeks and 3 months, and chronic when it lasts longer than 3 months. Most commonly, in about 85% of the patients, specific causative factors (e.g., infection, tumor, osteoporosis, fracture) cannot be found and the LBP is defined as nonspecific.,
The clinical course of an episode of acute LBP is characterized by fluctuation over time with frequent recurrences or exacerbations, rather than an acute, self-limiting course., Hestbaek et al. in a systemic review pointed out that after the first episode of LBP, about 62% of patients were still experiencing pain after 12 months. The estimated prevalence of chronic low back pain (CLBP) ranging from 35% to 75% at 12 months after the onset of pain.,,,,,, Many sources of persistent LBP have been identified, with lumbar intervertebral discs, facet joints, and sacroiliac joint being the most common. Intervertebral discs have been found to be the main source of CLBP with a percentage between 7% and 39%.,,
Until a few years ago, surgical intervention was the only treatment option for discogenic pain in patients unresponsive to conservative therapy. Surgical treatments include disc excision with laminectomy, open discectomy, microdiscectomy, spinal fusion, and artificial disc replacement. Altered bladder function and progressive muscle weakness are considered as absolute indications for surgery, but these are rare. The reported effectiveness and the incidence of complications vary with surgical procedures., Complication rate postsurgically has been reported to be around 17%–18%, including 20% risk of the failed back surgery syndrome,, and a 6%–22% re-intervention rate., According to the literature, poor patient selection is consistently reported as one of the causes for failed back surgery syndrome.,
More recently, minimally invasive intradiscal procedures have been considered as an alternative treatment approach for CLBP. The reported complication rate is low, the native disc structure is preserved, and the surrounding tissues are less affected with these procedures. The main purpose of the minimally invasive procedures is to avoid the major disadvantages of using surgical procedures, such as tissue trauma, high incidence of complications, and repeated surgeries.
| Materials and Methods|| |
We reviewed the international literature concerning the intradiscal therapies. The included articles were found through computerized searches in the electronic database of PubMed. The included papers were either reviews or original articles. The included studies were written in English language. Moreover, the articles were selected if percutaneous minimally invasive procedures were used as a treatment option in patients with CLBP. The follow-up in the selected papers included evaluation of back pain severity, functional improvement of the patients, as well as incidence of complications that presented. In total, this review study included 27 studies.
Thermal annular procedures
Internal disc degeneration (IDD) is considered as the causative factor in about 39% of total CLBP cases in adult population., Radial tears or fissures in the annulus can be caused by these degenerative changes. Disc material from the nucleus migrates outward through these rents, causing inflammation.
Thermal annular procedures (TAPs) are an alternative option between pharmacologic and surgical treatment for patients suffering from IDD. Three minimally invasive procedures have been developed: intradiscal electrothermal therapy (IDET), radiofrequency annuloplasty (RFA), and intradiscal biacuplasty (IDB). Heat is delivered by these procedures to the damaged annulus, leading to denervation of the annulus and pain relief. Heat-induced denaturation of collagen fibers is thought to stabilize the disc and potentially seal annular fissures.,
The effectiveness of TAPs is based on the strict and careful patient selection. The ideal patient  has LBP for at least 6 months, has back pain greater than leg pain, and is unresponsive to conservative treatment. Back pain is exacerbated by sitting or standing and is relieved by lying down. Moreover, positive well-performed discography, presence of an annular tear, and one or two affected intervertebral discs with at least 50% remaining disc height and disc bulges ≤5 mm are associated with favorable outcomes. Compressive radiculopathy and abnormal neurological examination are considered as contraindications for TAP.
Intradiscal electrothermal therapy
In IDET, a navigable intradiscal catheter that is radiologically guided into the outer posterior or posterolateral annulus is utilized and the produced heat is delivered to the affected disc while the patient is under conscious sedation lying prone., Temperature is thought to cause local denaturation of collagen fibrils, cauterization of granulation tissue, and coagulation of nerve fibers.,, Favorable outcomes in pain and disability can be achieved, when patients are selected correctly , [Table 1].
Meta-analyses assessing the efficacy of IDET procedure were conducted by Freeman  and Appleby et al. They reported a mean improvement in visual analog scale (VAS) for back pain of 3.4 and 2.9 points, respectively. In Oswestry disability index (ODI), the improvement was 5.2 and 7 points, respectively. In Appleby et al.'s  survey, the mean decrease in SF-36 physical function was 21.1 points and the mean decrease in SF-36 bodily pain was 18 points, all of which were statistically significant. The estimated incidence of complications was 0.8%. Freeman evaluated five retrospective studies with a total of 379 patients and between 13% and 23% of patients underwent surgery for persistence LBP after IDET procedure. He concluded that the evidence for the efficacy of IDET remains limited. However, in contrast to Freeman's conclusion, Appleby et al. pointed out that the effectiveness and the safety of the procedure have been confirmed by the outcomes of the published surveys.
The two randomized sham-controlled trials (RCTs) of the IDET procedure have conflicting findings. In a double-control trial, a total of 57 patients were randomized with 2:1 ratio, 38 being included in IDET group and 19 being included in sham procedure. The mean LBP outcome score for the IDET group was 39.51 at baseline and 38.31 at 6 months and that of for placebo group was 36.71 and 37.45, respectively. The mean ODI for the IDET group was 41.42 at baseline and 39.77 at 6 months and for the placebo group was 40.74 and 41.58, respectively. Outcome measures were not significantly improved after IDET or placebo treatment. In contrast to these findings, Pauza et al. demonstrated better outcomes for patients treated with IDET. Sixty-four patients included in the survey group and 37 were located to IDET group and 27 to sham treatments. They reported that patients in both groups improved in SF-36 score, whereas pain relief and ODI were improved significantly greater in IDET group than in sham group. They found that in patients who were presented with VAS <7, SF-36 <55, or ODI >40, IDET procedure was significantly more effective. Furthermore, >50% pain relief occurred only in 40% of patients treated with IDET and in 33% of participants in placebo group.
Both RCTs have been criticized. In Pauza et al.'s survey, extensive placebo effect has been reported, whereas the implementation of strict criteria in patient selection has led to outcomes which are uncertain if they could be extrapolated to clinical practice. On average, patients selected in the study were not disabled, with high scores for most of the subscales of the SF-36. Freeman's survey has been criticized for the failure of having a placebo effect. In contrast to the literature, Freeman's study has failed to demonstrate any beneficial outcome to IDET or sham group. The absence of placebo response suggests an undefined methodological error, and according to Helm et al., the study is nonresponsive in evaluating the null hypothesis that IDET is as effective as placebo in the treatment of CLBP. Furthermore, Freeman et al. included in their survey patients with marked functional limitations, whereas participants in Pauza et al.' survey  were less disabled and comparatively healthier.
Clinical outcomes of IDET procedure were compared with the outcomes of spinal fusion in a systemic review of Andersson et al. The overall median improvement after spinal fusion was 50% in VAS for pain, 42% in ODI, and 46% in SF-36. After IDET, the improvement was 51%, 14%, and 43%, respectively. The authors pointed out that perioperative complications were commonly associated with surgical intervention and concluded that IDET could be used before spinal fusion among eligible patients.
Radiofrequency thermal energy is delivered by RFA to the affected disc to treat LBP. Through an electrode, an alternating current (frequency, 250–500 kHz) is produced by a radiofrequency generator, causing ionic movements in the tissue directly surrounding the active tip. Molecular friction and heating of the tissue occur within a limited distance of the electrode. Cosman andCosman, as well as Kline, reported that RFA's efficacy is caused by de-activating the nerves suspected of contributing to pain, by applying an electrical current to coagulate the sensory nerves, and by preventing conduction of nociceptive impulses.
Clinical effectiveness of RFA procedure is reported in a prospective case–control study by Finch et al. Thirty-one participants underwent RFA in a single-level painful annular tear, and 15 patients continued conservative treatment. In treatment group, VAS and ODI were decreased significantly, whereas in control group, both outcome measures were unchanged over 12 months of follow-up.
Two RCTs for RFA have been conducted and showed no beneficial outcomes from the procedure. In Kvarstein et al.'s survey, 20 patients were distributed in treatment and sham group with a ratio of 1:1. Pain intensity scores and secondary outcome measures (ODI, SF-36, the percentage of patients' pain relief, and brief pain inventory) showed no significant differences between the groups neither at 6 months nor at 12 months follow-up. Five patients treated with RFA reported >50% pain relief at 12 months compared to only one patient in sham group. However, four patients in RFA group presented with worse or unchanged pain intensity in final follow-up, whereas in sham group, seven patients reported deterioration. In Barendse et al.'s  RCT, 13 patients were allocated in treatment group and 15 in sham group. No differences were reported in VAS for pain, global perceived effect, and ODI between the two groups 8 weeks after treatment.
In contrast to the results of Kvarstein et al. and Barendse et al., Oh et al. conducted an RCT and demonstrated clinical improvement postoperatively. In this survey, 49 patients were included suffering from CLBP for >1 year and whose pain continued after undergoing IDET. The control group patients each received an injection of lidocaine without RFA. At 4-month follow-up, in treatment group, VAS for pain and bodily pain and physical function subscales of SF-36 were significantly improved compared to control group. In control group, significant differences in these outcome measures were not found.
IDET and RFA procedures were compared in a prospective-matched control trial study by Kapural et al. Twenty-one patients were allocated to either group. Before treatment, statistically significant differences in VAS or pain disability index (PDI) were not found between the two groups. From the 3rd-month to the 12th-month postprocedure, participants in the IDET group were improved significantly greater in VAS and PDI than patients in RFA group.
In IDB, two cooled RF electrodes, which are included in a bipolar system, are placed on the posterolateral annulus fibrosus. The suggested process with regard to IDB is the coagulation of nociceptors within the posterior aspect of the disc. The produced temperature maintains a safe environment for the surrounding tissues, and at the same time, neural ablation is caused. Safety profile of the procedure and the absence of perioperative and postoperative complications have been reported in many studies in the literature.,,,
The effectiveness of IDB procedure was compared to that of a placebo intervention in Kapular et al.'s double-blinded RCT. At 6-month follow-up, physical function, pain, and disability were significantly improved in treated patients (n = 27) compared to patients in the sham group (n = 28). In IDB group, significant improvement was found in physical function and pain at 12-month follow-up. Participants with single-level disc degeneration appeared with better outcomes posttreatment compared to patients with two-level disc degeneration. At 6-month follow-up, patients in sham group were offered IDB and the improvement in physical function, pain, disability, and opioid usage at final follow-up was similar to those of patients who received IDB at inception. The authors provided evidence that IDB could be a minimally invasive option treatment in carefully selected patients and helped validate results of efficacy seen in earlier uncontrolled studies.,,
Safety and clinical effectiveness of IDB were demonstrated in Desai et al.'s  prospective, randomized study. The authors compared IDB and conventional medical management (CMM) (29 participants) with CMM-alone (34 participants). After 6 months, 89% of CMM-alone participants opted to receive IDB in addition to CMM. At 6-month and 12-month follow-up, patients in the original IDB + CMM group showed statistically significant pain relief and 55% of them presented with improvement in VAS >2 points. VAS score decreased >50% was documented in 41% of the patients, whereas physical function, ODI, and quality of life were improved significantly. At 6 months, none of the CMM-alone group average outcome scores were improved significantly. In cross-over group, the results at 6 months were more favorable than those observed in the CMM-alone group and were similar to the 6-month recorded outcomes in the originally treated IDB + CMM group.
A systemic review of the literature regarding the outcomes of TAPs for the treatment of CLBP was performed by Helm et al. Twelve observational studies and three RCTs were included in their survey. As mentioned above, RCTs of Pauza et al. and Freeman et al. had conflicting outcomes, whereas four observational studies ,, showed positive results for IDET, one observational study  showed negative results, and another showed undetermined results. Consequently, authors pointed out that IDET has an effect on health outcomes and they mentioned the necessity for further studies to determine the efficacy of the procedure. The authors included only one study for RFA, which showed no benefit, so the evidence for the efficacy of the procedure is poor. Investigators pointed out the insufficient evidence for the effectiveness of IDB.
Percutaneous disc decompression
Contained disc herniation in patients without abnormal neurological examination can be treated with percutaneous disc decompression (PDD). Open discectomy has been the primary modality for many years and is indicated in the minority of patients with persistent symptomatology. Hakkinen et al. estimated that the reoperation rate for lumbar disc herniation was 10% at 5-year follow-up, whereas Atlas et al. and Osterman et al. reported a 25% reoperation rate at 10-year follow-up. Open discectomy appears to have limited success rate in patients with small contained disc herniations, with recurrence of sciatica of 37.5% and reherniation rate of 12.5%.,,, In contrast, open discectomy appears beneficial in patients with noncontained disc herniations.
In PDD procedures, pain improvement is achieved by the relief of intradiscal pressure while the integrity of the surrounding tissues is preserved. As a consequence of intradiscal pressure reduction, inflammatory mediators' release is limited, whereas a reduction in disc size and an initiation of healing progress occur. Important predictive factor for the success of the PDD is to determine whether the disc herniation is still contained by intact fibers of the outer annulus and posterior longitudinal ligament.
Techniques included in PDD are chymopapain chemonucleolysis, which produces an enzymatic break of the nucleus, PDD (nucleoplasty), percutaneous laser disc decompression (PLDD), and automated percutaneous lumbar discectomy (APLD).,, Chymopapain is no longer used due to the increased risk for fatal anaphylaxis, cartilaginous endplate damage, and hemorrhage.,, The effectiveness of PDD is based on the strict and careful patient selection [Table 2].
|Table 2: Indications and contraindications for percutaneous disk decompression|
Click here to view
Percutaneous disc decompression (nucleoplasty)
Disc nucleoplasty (RF coblation or plasma discectomy) is a method of PDD using coblation technology. RF energy is produced through a 1-mm diameter bipolar instrument. Intradiscal pressure is reduced by removing approximately 1 cm ≥ of the nucleus pulposus, and the causing elimination in disc protrusion, as well as the decompression of the nerve root, has a good effect in pain relief.,, This technique preserves the integrity of the surrounding tissues, without direct mechanical or thermal damage. Consequently, risks associated with open surgery, such as fibrosis and infection, have been minimized., The most significant side effect is temporary soreness at the point of needle insertion, whereas discitis, both aseptic and septic, occur with rates between 0% and 1.2%.
Beneficial results of nucleoplasty were documented in Al-Zain et al.'s  prospective survey. Participants (n = 69) had a VAS score of 6.59 for back pain preoperatively and 3.36 after 1 year, whereas for radicular pain, the score was 5.68 and 2.5, respectively. These findings were statistically significant. At least 50% pain relief was reported in 58% of the participants. Similarly, clinical improvement postnucleoplasty was documented in Nedeljkovic's systematic review. Fourteen studies were included in the survey. Fifty-three percent of the patients reported >50% pain relief. The median percentage of improvement of VAS from baseline was 38.5%, with a range of 11%–72%. All studies reported improvement in VAS postnucleoplasty, but in nine studies, the improvement was statistically significant. Three studies assessed patients' functional improvement and concluded that over 50% of the participants were presented with improvement in the final follow-up.
A comprehensive meta-analysis was conducted to analyze the effectiveness and safety of the procedure in treating lumbar and cervical disc herniations. Eichen et al. evaluated 27 studies, with a total of 3211 patients, and concluded that procedure reduces pain in the long term and increases patients' functional mobility. In 17 studies, VAS and numeric pain scale were utilized as outcome measures, and nucleoplasty led to statistically significant pain reduction compared to baseline at every measurement time point. Four studies had control groups and nucleoplasty was found to be more effective than conservative treatment after 6 weeks and 3 months. ODI was decreased significantly compared to baseline across all time points.
Effectiveness of nucleoplasty against fluoroscopy-guided transforaminal epidural steroid injection (TFESI) was tested in an RCT. Forty-six participants were allocated in PDD group and 44 in TFESI group. VAS for leg pain, ODI, and SF-36 were improved significantly greater in nucleolasty group compared to those in TFESI group. During the 2-year follow-up period, 25 (56%) patients in nucleoplasty group and 11 (28%) in the TFESI group have not undergone a secondary procedure.
It has been mentioned that nucleoplasty and PDD techniques are indicated in patients with contained disc herniation. The assumption that patients with larger protrusion will have less favorable outcomes from nucleoplasty was assessed in a prospective, nonrandomized, cohort study. Three groups of patients were evaluated. In Subgroup 1A, 24 patients were included with a disc protrusion ≤5 mm; in Subgroup 1B, those with a disc protrusion size 6 mm–9 mm are included, and in Group 2, 27 patients were allocated with a disc extrusion. All of them were treated with nucleoplasty. Sixty-five patients with disc extrusion were allocated in Group 3 and were treated with microdiscectomy. Comparing Subgroup 1A with Subgroup 1B, it was found that both subgroups were equal concerning pain severity and disability after 1-year follow-up. In Group 2, statistically significant exacerbation of pain severity and disability was documented during the first 3 months, and a further stabilization of patients' condition was found during the next follow-ups. In Group 3, during the first 6 months, pain intensity and disability were decreased significantly. The authors concluded that total annulus disruption in cases of disc extrusion is associated with poor results and less pain relief when treated with nucleoplasty. On the contrary, nucleoplasty appeared to have beneficial outcome for contained disc herniations up to 9 mm.
Percutaneous laser disc decompression
PLDD is one minimally invasive treatment modality for contained lumbar disc herniation, which has been approved by Food and Drug Administration since 1991. In PLDD, laser energy is delivered by a laser fiber through a hollow needle placed into the nucleus pulposus via a percutaneous approach under local anesthesia. Water content of the nucleus pulposus is vaporized due to laser energy, causing a decrease in intradiscal volume and a subsequent reduction in intradiscal pressure.,,, In Hellinger's survey, 3377 patients were evaluated and a complication rate of 0.5% was reported. One case of infectious discitis was documented among 377 PLDD procedures, whereas three cases of abdominal perforation and one of partial cauda equina syndrome were caused due to PLDD according to Quigley's study.
The limited evidence for the short-term and long-term effectiveness of PLDD has been reported in systemic reviews., In Singh et al.'s  study, among 3171 patients, 75% experienced clinical improvement for at least 1 year. In Schenk et al.'s  review, 16 clinical trials were included with a total of 1579 patients. Schenk et al., as well as Singh et al., concluded that PLDD may be effective in properly selected patients and mentioned the paucity of RCTs.
The first RCT comparing the effectiveness of PLDD to conventional surgery in patients with lumbosacral radicular syndrome was conducted by Brouwer et al. Fifty-seven patients were included in PLDD group and 58 patients allocated in surgery group. Statistically significant differences were not found in outcome measures (Roland–Morris disability questionnaire, VAS for pain, and seven-point Likert scale) between the two groups, except for a faster recovery for patients underwent surgery. In PLDD group, 24 patients (44%) had undergone to additional surgical intervention during the 1st year, whereas nine of the patients (16%) had undergone surgery needed a reoperation. Surgery group demonstrated more complications (11%) compared to PLDD group in which complications occurred less commonly (5%). The authors concluded that PLDD, with additional surgery when needed, can be a treatment option with effectiveness similar to surgical intervention.
The same conclusion was led by Tassi, who compared microdiscectomy to PLDD, in a 2-year follow-up. In microdiscectomy group (n = 500), clinical improvement occurred in 85.7% of the patients, whereas the remaining patients (14.3%) deteriorated or did not improve. In PLDD group (n = 500), the percentages were 83.8% and 16.2%, respectively. Clinical improvement occurred more quickly in surgery group, whereas recovery time was significantly shorter in PLDD group. Complication rate in microdiscectomy group was 2.2%, whereas in PLDD group, complications did not occur.
Automated percutaneous lumbar discectomy
A pneumatically driven, suction-cutting probe is utilized in APLD and is placed in the affected disc through a cannula that has a 2.8-mm outer diameter. Three grams of disc material is removed 1 cm anterior to the herniation, thus leading to reduction of intradiscal pressure and decompression of the nerve root.
In a prospective multi-institutional study, the results of 1582 APLD procedures from 1992 to 1994 were evaluated. The reported success rate was 83% at 1 year. Similarly, in Manchikanti et al.'s  review, positive results occurred in 80% of the patients. Patients with disc protrusion improved significantly greater compared to patients with disc sequestration and to patients with <2 years symptoms duration. In contrast to the common philosophy, Teng et al. reported that patients with LBP as a predominant symptom improved significantly greater than those with classic sciatica.
In a comparative study by Liu et al., 104 patients were treated with APLD and 82 patients were treated with microendoscopic discectomy (MED) with a mean follow-up period of 6 years. According to MacNab criteria, success rate of 75.96% in APLD group and 84.15% in the MED group was reported. Patients treated with MED had significantly greater improvement in ODI and SF-36 scores of social functioning and bodily pain than those in APLD group. Eight patients (7.69%) in the APLD group and two patients (2.44%) in the MED group underwent open surgical discectomy. While long-term postprocedural satisfaction is greater in patients underwent MED, incidence of complications, duration of hospitalization, and costs are lower for patients in APLD group.
Two RCTs have been performed to evaluate the effectiveness of APLD, but the quality and the results of the studies have been criticized. Chatterjee et al. conducted an RCT comparing APLD to microdiscectomy. Twenty-nine percent of patients in APLD group and 80% of patients in microdiscectomy group showed beneficial outcomes. The authors have been criticized for poor selection criteria, for unreasonably low success rate with APLD, which may be even less than with placebo, and for not using CT discography. The absence of control group limits the quality of the RCT. The second RCT was conducted by Haines et al. and compared the effectiveness of APLD to the effectiveness of conventional discectomy. According to Macnab criteria, the success rate of APLD was 41% of the percutaneous discectomy patients and 40% of the conventional discectomy. Haines et al. failed to recruit sufficient number of participants and only 34 patients were included in the survey.
Characteristics and results of the published surveys for intradiscal minimally invasive procedures are presented in [Table 3].
| Conclusions|| |
Patients who underwent IDET procedure presented 51% improvement in VAS score, 14% in ODI, and 46% in SF-36, whereas the complications were approximately 0.8%., Concerning RFA, it seems that the results are not so beneficial. IDB in combination with CMM showed 55% pain relief, whereas disc showed relief of the pain in 58% of the patients. PLDD results have been reported beneficial in 75% of the patients.
In the Swedish Lumbar Spine Study  at 2-year follow-up, the mean decrease in back pain was 33% in the surgical group and 7% in the nonsurgical group. In the Norwegian study, at 1-year follow-up, improvement in back pain was not different between lumbar fusion group and control group. In the UK Medical Research Council trial, spinal fusion was compared to an intensive program of exercise therapy, spine stabilization exercises, and education using cognitive-behavioral principals. At a 2-year follow-up, it was found that pain, ODI, quality of life, or SF-36 physical or mental components did not statistically differ between the two treatment approaches. The European guidelines support that fusion surgery cannot be recommended unless 2 years of conservative treatment or minimally invasive procedures have failed.
Therefore, the short-term indication for medications, as well as the increased complication rate and the variable success rate of surgery, leads to an increased interest for minimally invasive procedures. Since 1998, IDET procedure has been performed and the reported incidence of complications is low. In properly selected patients with internal disc disruption who underwent IDET, the need for surgical intervention may be obviated or delayed for an extended period. The American Society of Interventional Pain Physicians concluded in their 2007 evidence-based practice guidelines in the management of CLBP that the evidence for IDET was moderate for short-term and long-term pain relief. In addition, the North American Spine Society suggests that for less disabled patients with annular tears or protrusions <3 mm–4 mm and relatively well-preserved disc heights, IDET would seem to be a reasonable primary option treatment.
In contrast to IDET, there is far less literature on RFA and IDB procedures. There are little data on the effectiveness of RFA and IDB, and according to Helm et al., the evidence is limited for both procedures regarding whether they are effective in relieving discogenic CLBP. One prospective survey  compared IDET to RFA and concluded that IDET should be the preferable treatment option for discogenic CLBP. Further high-quality surveys are needed to assess the effectiveness of RFA and IDB and to provide efficient evidence for their use in the management of CLBP.
According to the results of many studies, nucleoplasty is regarded as a potentially effective treatment approach in patients with discogenic LBP. Increased success rates have been reported and average pain reduction is significant, while the procedure is safe and well tolerated from the patients. Prospective RCTs with higher quality of evidence are necessary to confirm the efficacy of the procedure. Similarly, increased success rates have been found in observational studies and systemic reviews for PLDD. These findings have been validated by Brouwer et al.'s RCT. The authors mentioned the efficacy of the procedure and the need for surgical intervention if the symptoms persist. APLD has been approved by the American Academy of Orthopedic Surgeons as a treatment option for patients with herniated lumbar discs. Prospective studies have reported favorable clinical outcomes and the importance of strict patient selection is acknowledged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Salovey P. Reporting Chronic Pain Episodes on Health Surveys. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics; 1992.
Schizas C, Kulik G, Kosmopoulos V. Disc degeneration: Current surgical options. Eur Cell Mater 2010;20:306-15.
Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA; American Society of Interventional Pain Physicians. Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician 2009;12:E35-70.
Walker BF. The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J Spinal Disord 2000;13:205-17.
Knox J, Orchowski J, Scher DL, Owens BD, Burks R, Belmont PJ, et al.
The incidence of low back pain in active duty United States military service members. Spine (Phila Pa 1976) 2011;36:1492-500.
Helm Ii S, Deer TR, Manchikanti L, Datta S, Chopra P, Singh V, et al
. Effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician 2012;15:E279-304.
Hildebrandt J, Holger U, Mannion A, Airaksinen O, Ivar Brox J, Cedraschi C, et al
. European Guidelines for the Management of Chronic Non-specific Low Back Pain. Norway: European Commission, Research Directorate-General, Department of Policy, Co-Ordination and Strategy; 2004.
Van Tulder M, Koes B. Low back pain (chronic). Clin Evid 2006;15:1634-53.
Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al
. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15 Suppl 2:S192-300.
Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
Krismer, M, van Tulder M; Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol 2007;21:77-91.
Von Korff M. Studying the natural history of back pain. Spine (Phila Pa 1976) 1994;19:2041S-6S.
van Tulder M, Koes B, Bombardier C. Low back pain. Best Pract Res Clin Rheumatol 2002;16:761-75.
Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: What is the long-term course? A review of studies of general patient populations. Eur Spine J 2003;12:149-65.
Carey TS, Garrett JM, Jackman A, Hadler N. Recurrence and care seeking after acute back pain: Results of a long-term follow-up study. North Carolina back pain project. Med Care 1999;37:157-64.
Wahlgren DR, Atkinson JH, Epping-Jordan JE, Williams RA, Pruitt SD, Klapow JC, et al.
One-year follow-up of first onset low back pain. Pain 1997;73:213-21.
Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: A prospective study. BMJ 1998;316:1356-9.
Elliott AM, Smith BH, Hannaford PC, Smith WC, Chambers WA. The course of chronic pain in the community: Results of a 4-year follow-up study. Pain 2002;99:299-307.
Enthoven P, Skargren E, Oberg B. Clinical course in patients seeking primary care for back or neck pain: A prospective 5-year follow-up of outcome and health care consumption with subgroup analysis. Spine (Phila Pa 1976) 2004;29:2458-65.
Miedema H, Chorus A, Wevers C, van der Linden S. Chronicity of back problems during working life. Spine (Phila Pa 1976) 1998;23: 21-8.
Lambeek LC, Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ 2010;340:c1035.
Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N, et al.
The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine (Phila Pa 1976) 1995;20:1878-83.
Kallewaard JW, Terheggen MA, Groen GJ, Sluijter ME, Derby R, Kapural L, et al.
15 Discogenic low back pain. Pain Pract 2010;10:560-79.
Kapural L, Mekhail N. Novel intradiscal biacuplasty (IDB) for the treatment of lumbar discogenic pain. Pain Pract 2007;7:130-4.
Pomerantz SR, Hirsch JA. Intradiscal therapies for discogenic pain. Semin Musculoskelet Radiol 2006;10:125-35.
Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev 2007;1:CD001350.
Fritzell P, Hagg O, Wessberg P, Nordwall A. Lumbar fusion versus nonsurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish lumbar Spine study group. Spine 2001;26:2521-32.
Kuijpers T, van Middelkoop M, Rubinstein SM, Ostelo R, Verhagen A, Koes BW, et al
. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J 2011;20:40-50.
Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA, et al.
Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila Pa 1976) 2007;32:382-7.
Follett KA, Dirks BA. Etiology and evaluation of the failed back surgery syndrome. Neurosurg Q 1993;3:40.
Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine lumbar spine study. Spine (Phila Pa 1976) 2005;30:927-35.
Goupille P. Causes of failed back surgery syndrome. Rev Rhum Engl Ed 1996;63:235-9.
Van Goethem JW, Parizel PM, van den Hauwe L, De Schepper AM. Imaging findings in patients with failed back surgery syndrome. J Belge Radiol 1997;80:81-4.
Singh V, Manchikanti L, Calodney AK, Staats PS, Falco FJ, Caraway DL, et al.
Percutaneous lumbar laser disc decompression: An update of current evidence. Pain Physician 2013;16:SE229-60.
Tassi GP. Comparison of results of 500 microdiscectomies and 500 percutaneous laser disc decompression procedures for lumbar disc herniation. Photomed Laser Surg 2006;24:694-7.
Norlund A, Waddell G. Cost of back pain in some OECD countries. Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis and Treatment. Vol. 1. Nachemson AL, Jonsson E, editor. Philadelphia: Lippincott, Williams & Wilkins; 2000. p. 421-5.
Helm S, Hayek SM, Benyamin RM, Manchikanti L. Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician 2009;12:207-32.
Mazin DA, Sullivan JP. Lumbar and sacral radiofrequency neurotomy. Phys Med Rehabil Clin N
Wall MS, Deng XH, Torzilli PA, Doty SB, O'Brien SJ, Warren RF, et al.
Thermal modification of collagen. J Shoulder Elbow Surg 1999;8:339-44.
Karasek M, Bogduk N. Intradiscal electrothermal annuloplasty: Percutaneous treatment of chronic discogenic low back pain. Tech Reg Anesth Pain Manag 2001;5:130-5.
Pauza KJ, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27-35.
Kloth DS, Fenton DS, Andersson GB, Block JE. Intradiscal electrothermal therapy (IDET) for the treatment of discogenic low back pain: Patient selection and indications for use. Pain Physician 2008;11:659-68.
Raj PP. Intervertebral disc: Anatomy-physiology-pathophysiology-treatment. Pain Pract 2008;8:18-44.
Derby R, Baker RM, Lee CH, Anderson PA. Evidence-informed management of chronic low back pain with intradiscal electrothermal therapy. Spine J 2008;8:80-95.
Shah RV, Lutz GE, Lee J, Doty SB, Rodeo S. Intradiskal electrothermal therapy: A preliminary histologic study. Arch Phys Med Rehabil 2001;82:1230-7.
Bono CM, Iki K, Jalota A, Dawson K, Garfin SR. Temperatures within the lumbar disc and endplates during intradiscal electrothermal therapy: Formulation of a predictive temperature map in relation to distance from the catheter. Spine (Phila Pa 1976) 2004;29:1124-9.
Freeman BJ. IDET: A critical appraisal of the evidence. Eur Spine J 2006;15 Suppl 3:S448-57.
Appleby D, Andersson G, Totta M. Meta-analysis of the efficacy and safety of intradiscal electrothermal therapy (IDET). Pain Med 2006;7:308-16.
Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC. A randomized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine (Phila Pa 1976) 2005;30:2369-77.
Andersson GB, Mekhail NA, Block JE. Treatment of intractable discogenic low back pain. A systematic review of spinal fusion and intradiscal electrothermal therapy (IDET). Pain Physician 2006;9:237-48.
Maas ET, Ostelo RW, Niemisto L, Jousimaa J, Hurri H, Malmivaara A, et al.
Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev 2015;10:CD008572.
Kline M, Yin W. Radiofrequency techniques in clinical practice. In: Interventional Pain Management. 2nd
ed. Waldman S ed, WB Saunders, Philadelphia, 2002, pp 243-93.
Cosman ER Jr., Cosman ER Sr. Electric and thermal field effects in tissue around radiofrequency electrodes. Pain Med 2005;6:405-24.
Finch PM, Price LM, Drummond PD. Radiofrequency heating of painful annular disruptions: One-year outcomes. J Spinal Disord Tech 2005;18:6-13.
Kvarstein G, Måwe L, Indahl A, Hol PK, Tennøe B, Digernes R, et al.
A randomized double-blind controlled trial of intra-annular radiofrequency thermal disc therapy – A 12-month follow-up. Pain 2009;145:279-86.
Barendse GA, van Den Berg SG, Kessels AH, Weber WE, van Kleef M. Randomized controlled trial of percutaneous intradiscal radiofrequency thermocoagulation for chronic discogenic back pain: Lack of effect from a 90-second 70 C lesion. Spine (Phila Pa 1976) 2001;26:287-92.
Oh WS, Shim JC. A randomized controlled trial of radiofrequency denervation of the ramus communicans nerve for chronic discogenic low back pain. Clin J Pain 2004;20:55-60.
Kapural L, Hayek S, Malak O, Arrigain S, Mekhail N. Intradiscal thermal annuloplasty versus intradiscal radiofrequency ablation for the treatment of discogenic pain: A prospective matched control trial. Pain Med 2005;6:425-31.
Kapural L, Vrooman B, Sarwar S, Krizanac-Bengez L, Rauck R, Gilmore C, et al.
A randomized, placebo-controlled trial of transdiscal radiofrequency, biacuplasty for treatment of discogenic lower back pain. Pain Med 2013;14:362-73.
Kapural L, Vrooman B, Sarwar S, Krizanac-Bengez L, Rauck R, Gilmore C, et al.
Radiofrequency intradiscal biacuplasty for treatment of discogenic lower back pain: A 12-month follow-up. Pain Med 2015;16:425-31.
Kapural L, Ng A, Dalton J, Mascha E, Kapural M, de la Garza M, et al.
Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: Results of a six-month follow-up. Pain Med 2008;9:60-7.
Karaman H, Tufek A, Olmez Kavak G, Kaya S, Baysal Yildirim Z, Uysak E, et al
. 6-month results of trans discal biacuplasty on patients with discogenic low back pain: Preliminary findings. Int J Med Sci 2010;8:1-8.
Desai MJ, Kapural L, Petersohn JD, Vallejo R, Menzies R, Creamer M, et al.
Twelve-month follow-up of a randomized clinical trial comparing intradiscal biacuplasty to conventional medical management for discogenic lumbar back pain. Pain Med 2017;18:751-63.
Bogduk N, Lau P, Gowaily K. An audit of radiofrequency biacuplasty for back pain due to internal disc disruption. Pain Med 2009;10:947.
Kapural L, Cata JP, Narouze S. Successful treatment of lumbar discogenic pain using intradiscal biacuplasty in previously discectomized disc. Pain Pract 2009;9:130-4.
Tsou HK, Chao SC, Kao TH, Yiin JJ, Hsu HC, Shen CC, et al
. Intradiscal electrothermal therapy in the treatment of chronic low back pain: Experience with 93 patients. Surg Neurol Int 2010;1:37.
Assietti R, Morosi M, Migliaccio G, Meani L, Block JE. Treatment of discogenic low back pain with intradiscal electrothermal therapy (IDET): 24 months follow-up in 50 consecutive patients. Acta Neurochir Suppl 2011;108:103-5.
Nunley PD, Jawahar A, Brandao SM, Wilkinson KM. Intradiscal electrothermal therapy (IDET) for low back pain in worker's compensation patients: Can it provide a potential answer? Long-term results. J Spinal Disord Tech 2008;21:11-8.
Davis TT, Delamarter RB, Sra P, Goldstein TB. The IDET procedure for chronic discogenic low back pain. Spine (Phila Pa 1976) 2004;29:752-6.
Derby R, Eek B, Lee SH, Seo KS, Kim BJ. Comparison of intradiscal restorative injections and intradiscal electrothermal treatment (IDET) in the treatment of low back pain. Pain Physician 2004;7:63-6.
Gerszten PC, Smuck M, Rathmell JP, Simopoulos TT, Bhagia SM, Mocek CK, et al.
Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: A prospective, randomized, controlled trial. J Neurosurg Spine 2010;12:357-71.
Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse: Updated cochrane review. Spine (Phila Pa 1976) 2007;32:1735-47.
Hakkinen A, Kiviranta I, Neva MH, Kautiainen H, Ylinen J. Reoperations after first lumbar disc herniation surgery; A special interest on residives during a 5-year follow-up. BMC Musculoskelet Disord 2007;8:2.
Osterman H, Sund R, Seitsalo S, Keskimäki I. Risk of multiple reoperations after lumbar discectomy: A population-based study. Spine (Phila Pa 1976) 2003;28:621-7.
Astrand P, Määttänen H, Vucetic N, Svensson O. Pain and orthopaedic and neurologic signs after lumbar discectomy: A 2-year followup. Clin Orthop Relat Res 2000;379:154-60.
Carragee EJ, Han MY, Suen PW, Kim D. Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am 2003;85-A: 102-8.
Ng LC, Sell P. Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study. J Bone Joint Surg Br 2004;86:546-9.
Vucetic N, Astrand P, Güntner P, Svensson O. Diagnosis and prognosis in lumbar disc herniation. Clin Orthop Relat Res 1999;361:116-22.
Dewing CB, Provencher MT, Riffenburgh RH, Kerr S, Manos RE. The outcomes of lumbar microdiscectomy in a young, active population: Correlation by herniation type and level. Spine (Phila Pa 1976) 2008;33:33-8.
Nedeljkovic SS. A systematic review on the effectiveness of the nucleoplastytm procedure for discogenic pain. Pain Physician 2010;13:117-32.
Derby R, Kine G, Saal JA, Reynolds J, Goldthwaite N, White AH, et al
. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine 1992;17:S176-83.
Patel VB, Wasserman R, Imani F. Interventional therapies for chronic low back pain: A focused review (efficacy and outcomes). Anesth Pain Med 2015;5:e29716.
Alò KM, Wright RE, Sutcliffe J, Brandt SA. Percutaneous lumbar discectomy: Clinical response in an initial cohort of fifty consecutive patients with chronic radicular pain. Pain Pract 2004;4:19-29.
Andreula C, Muto M, Leonardi M. Interventional spinal procedures. Eur J Radiol 2004;50:112-9.
Takegami K, An HS, Kumano F, Chiba K, Thonar EJ, Singh K, et al
. Osteogenic protein-1 is most effective in stimulating nucleus pulposus and annulus fibrosus cells to repair their matrix after chondroitinase ABC–induced in vitro
chemonucleolysis. Spine J 2005;5:231-8.
Al-Zain F, Lemcke J, Killeen T, Meier U, Eisenschenk A. Minimally invasive spinal surgery using nucleoplasty: A 1-year follow-up study. Acta Neurochir 2008;150:1257-62.
Bokov A, Skorodumov A, Isrelov A, Stupak Y, Kukarin A. Differential treatment of nerve root compression pain caused by lumbar disc herniation applying nucleoplasty. Pain Physician 2010;13:469-80.
Chen YC, Lee SH, Saenz Y, Lehman NL. Histologic findings of disc, end plate and neural elements after coblation of nucleus pulposus: An experimental nucleoplasty study. Spine J 2003;3:466-70.
Mirzai H, Tekin I, Yaman O, Bursali A. The results of nucleoplasty in patients with lumbar herniated disc: A prospective clinical study of 52 consecutive patients. Spine J 2007;7:88-92.
Slipman C, Frey M, Lee A, Richards J, Isaac Z, Nirschl M, et al
. Preliminary Data: Side Effects and Complications of Lumbar Nucleoplasty, in Presented at NASS Spine Across the Sea; 2003.
Eichen PM, Achilles N, Konig V, Mosges R, Hellmich M, Himpe B, et al
. Nucleoplasty, a minimally invasive procedure for disc decompression: A systematic review and meta-analysis of published clinical studies. Pain Physician 2014;17:E149-73.
Schenk B, Brouwer PA, Peul WC, van Buchem MA. Percutaneous laser disk decompression: A review of the literature. AJNR Am J Neuroradiol 2006;27:232-5.
Goupille P, Mulleman D, Mammou S, Griffoul I, Valat JP. Percutaneous laser disc decompression for the treatment of lumbar disc herniation: Review. Semin Arthritis Rheum 2007;37:20-30.
Choy DS, Diwan S.In vitro
and in vivo
fall of intradiscal pressure with laser disc decompression. J Clin Laser Med Surg 1992;10:435-7.
Choy DS, Altman P. Fall of intradiscal pressure with laser ablation. J Clin Laser Med Surg 1995;13:149-51.
Choy DS. Percutaneous laser disc decompression (PLDD): Twelve years' experience with 752 procedures in 518 patients. J Clin Laser Med Surg 1998;16:325-31.
Hellinger J. Complications of non-endoscopic percutaneous laser disc decompression and nucleotomy with the neodymium: YAG laser 1064 nm. Photomed Laser Surg 2004;22:418-22.
Quigley MR. Percutaneous laser discectomy. Neurosurg Clin N
Brouwer PA, Brand R, van den Akker-van Marle ME, Jacobs WC, Schenk B, van den Berg-Huijsmans AA, et al
. Percutaneous laser disc decompression versus conventional microdiscectomy in sciatica: A randomized controlled trial. Spine J 2015;15:857-65.
Manchikanti L, Singh V, Falco FJ, Calodney AK, Onyewu O, Helm S 2nd
, et al
. An updated review of automated percutaneous mechanical lumbar discectomy for the contained herniated lumbar disc. Pain Physician 2013;16 2 Suppl: SE151-84.
Teng GJ, Jeffery RF, Guo JH, He SC, Zhu HZ, Wang XH, et al
. Automated percutaneous lumbar discectomy: A prospective multi-institutional study. J Vasc Interv Radiol 1997;8:457-63.
Manchikanti L, Singh V, Calodney AK, Helm S 2nd
, Deer TR, Benyamin RM, et al.
Percutaneous lumbar mechanical disc decompression utilizing Dekompressor ®
: An update of current evidence. Pain Physician 2013;16 2 Suppl:SE1-24.
Liu WG, Wu XT, Guo JH, Zhuang SY, Teng GJ. Long-term outcomes of patients with lumbar disc herniation treated with percutaneous discectomy: Comparative study with microendoscopic discectomy. Cardiovasc Intervent Radiol 2010;33:780-6.
Chatterjee S, Foy PM, Findlay GF. Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Spine 1995;20:734-8.
Haines SJ, Jordan N, Boen JR, Nyman JA, Oldridge NB, Lindgren BR, et al
. Discectomy strategies for lumbar disc herniation: results of the LAPDOG trial. J Clin Neurosci 2002;9:411-7.
Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, et al
. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises for the postlaminectomy syndrome. In: Annals of the Rheumatic Diseases. England: BMJ Publishing Group British Med Assoc House, Tavistock Square, London Wc1h 9jr; 2003.
Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R, et al
. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: The MRC spine stabilisation trial. BMJ 2005;330:1233.
Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, et al.
Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007;10:7-111.
Onik G, Helms CA. Automated percutaneous lumbar diskectomy. AJR Am J Roentgenol 1991;156:531-8.
[Table 1], [Table 2], [Table 3]