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Nonoperative Management of Discogenic Back Pain: A Systematic Review

Lu, Young BA; Guzman, Javier Z. BS; Purmessur, Devina PhD; Iatridis, James C. PhD; Hecht, Andrew C. MD; Qureshi, Sheeraz A. MD, MBA; Cho, Samuel K. MD

doi: 10.1097/BRS.0000000000000401
Literature Review

Study Design. Systematic review of the literature.

Objective. A systematic evaluation of the literature was performed to investigate current nonoperative management of the treatment of discogenic low back pain.

Summary of Background Data. Back pain is a major health care concern with up to 39% being discogenic in origin according to one study. Nonoperative therapy is likely to be the initial treatment strategy for discogenic low back pain.

Methods. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for clinical studies evaluating nonoperative methods of treating discogenic back pain that were published between 2000 and 2012. Only prospective randomized controlled studies that compared a nonsurgical intervention with sham or placebo therapy were included. After removal of duplicate citations, a total of 226 articles were initially identified from the search terms. From these, we identified 11 randomized controlled trials (RCTs) from which data analysis was performed.

Results. The 11 RCTs investigated traction therapy, injections, and ablative techniques. Results from 5 RCTs investigating methylene blue injection, steroid injection, ramus communicans ablation, intradiscal electrothermal therapy, and biacuplasty favored intervention over sham therapy. However, results from the study on methylene blue injections have not been replicated in other RCTs. Evaluation of the selection criteria used in the studies on ramus communicans ablation and intradiscal biacuplasty and a stratified analysis of results from the RCTs on intradiscal electrothermal therapy casts doubt on whether the conclusions from these RCTs can be applied to the general patient population with discogenic pain.

Conclusion. There are few high-quality studies evaluating nonoperative treatments for reducing discogenic low back pain. Although conclusions from several studies favor intervention over sham, it is unclear whether these interventions confer stable long-term benefit. There is some promise in newer modalities such as biacuplasty; however, more inclusive studies need to be performed.

Level of Evidence: 2

Supplemental Digital Content is Available in the Text.Although discogenic back pain causes a significant socioeconomic burden on society, there are few nonoperative management options. Systematic review of literature yielded 11 randomized controlled trials addressing this topic. Treatments including ablative therapy and physical modalities have been largely ineffective. Although there is some potential for long-term benefits with intradiscal methylene blue injections, further studies are needed to characterize its clinical effectiveness and safety profile.

From the Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.

Address correspondence and reprint requests to Samuel K. Cho, MD, Leni and Peter W. May Department of Orthopaedic Surgery, Mount Sinai Medical Center, 5 East 98 St, 9th Floor, New York, NY 10029; E-mail:

Acknowledgment date: November 12, 2013. First revision date: February 22, 2014. Second revision date: April 3, 2014. Acceptance date: April 3, 2014.

The manuscript submitted does not contain information about medical device(s)/drug(s).

NIH/NIAMS (grants R01AR057397 and R01 AR064157) funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants, royalties, board membership.

© 2014 by Lippincott Williams & Wilkins