Nonsurgical Interventional Therapies for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline

Study Design. Systematic review. Objective. To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain. Summary of Background Data. Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy. Methods. Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. Results. For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies. Conclusion. Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

[1]  A. Jadad,et al.  Meta-analyses to evaluate analgesic interventions: a systematic qualitative review of their methodology. , 1996, Journal of clinical epidemiology.

[2]  R. Fraser,et al.  Chymopapain. A 10-year, double-blind study. , 1992, Spine.

[3]  B. Greenwald,et al.  Critical Review of Prolotherapy for Osteoarthritis, Low Back Pain, and other Musculoskeletal Conditions: A Physiatric Perspective , 2004, American journal of physical medicine & rehabilitation.

[4]  G. Andersson,et al.  Treatment of intractable discogenic low back pain. A systematic review of spinal fusion and intradiscal electrothermal therapy (IDET). , 2006, Pain physician.

[5]  G. Kingsley,et al.  Outpatient lumbar epidural corticosteroid injection in the management of sciatica. , 1988, British journal of rheumatology.

[6]  R. Deyo,et al.  Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications , 2004, Pain.

[7]  D. Brocai,et al.  Epidural Corticosteroid Injection in the Conservative Management of Sciatica , 2000, Clinical orthopaedics and related research.

[8]  S. Fuchs,et al.  Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular pain in the lumbar spine. , 2005, Journal of vascular and interventional radiology : JVIR.

[9]  T. Hoogland,et al.  Transforaminal Posterolateral Endoscopic Discectomy With or Without the Combination of a Low-Dose Chymopapain: A Prospective Randomized Study in 280 Consecutive Cases , 2006, Spine.

[10]  Y. Maugars,et al.  Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study. , 1996, British journal of rheumatology.

[11]  A. Martins,et al.  Double-blind evaluation of intradiscal chymopapain for herniated lumbar discs. Early results. , 1976, Journal of neurosurgery.

[12]  Marie E. Latulippe,et al.  A controlled trial of corticosteroid injections into facet joints for chronic low back pain. , 1991, The New England journal of medicine.

[13]  R. Stolker,et al.  Efficacy of Radiofrequency Procedures for the Treatment of Spinal Pain: A Systematic Review of Randomized Clinical Trials , 2001, Regional Anesthesia & Pain Medicine.

[14]  İ. Tekin,et al.  A Comparison of Conventional and Pulsed Radiofrequency Denervation in the Treatment of Chronic Facet Joint Pain , 2007, The Clinical journal of pain.

[15]  A. Carr,et al.  A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain. , 1999, Rheumatology.

[16]  C. Stevens,et al.  Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation , 2005, Sozial- und Präventivmedizin.

[17]  Donald D. McGeary,et al.  A Randomized Clinical Trial of Treatment for Lumbar Segmental Rigidity , 2004, Spine.

[18]  S. Morley,et al.  Intrathecal midazolam for the treatment of chronic mechanical low back pain: a controlled comparison with epidural steroid in a pilot study , 1992, Pain.

[19]  P. Wennerstrand,et al.  Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint. , 2002, Clinical and experimental rheumatology.

[20]  M. Rossignol,et al.  Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. , 2002, Spine.

[21]  J. Gibson,et al.  Surgical Interventions for Lumbar Disc Prolapse: Updated Cochrane Review , 2007, Spine.

[22]  L. Manchikanti,et al.  One day lumbar epidural adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: a randomized, double-blind trial. , 2004, Pain physician.

[23]  E. Buchser,et al.  Spinal cord stimulation versus conventional medical management for neuropathic pain: A multicentre randomised controlled trial in patients with failed back surgery syndrome , 2007, Pain.

[24]  Pekka Rissanen,et al.  A Randomized Trial of Combined Manipulation, Stabilizing Exercises, and Physician Consultation Compared to Physician Consultation Alone for Chronic Low Back Pain , 2003, Spine.

[25]  M. Gofeld.  Radiofrequency facet denervation: a randomized control placebo versus sham procedure. , 2006, The Clinical journal of pain.

[26]  M. B. Taylor,et al.  Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial. , 2005, British journal of anaesthesia.

[27]  M. Boswell,et al.  Therapeutic facet joint interventions in chronic spinal pain: a systematic review of effectiveness and complications. , 2005, Pain physician.

[28]  G. Úrrutia,et al.  Percutaneous Thermocoagulation Intradiscal Techniques for Discogenic Low Back Pain , 2007, Spine.

[29]  J. Turner,et al.  Spinal cord stimulation for chronic low back pain: a systematic literature synthesis. , 1995, Neurosurgery.

[30]  K. Pettersson,et al.  Percutaneous Lumbar Zygapophysial (Facet) Joint Neurotomy Using Radiofrequency Current, in the Management of Chronic Low Back Pain: A Randomized Double-Blind Trial , 2008, Spine.

[31]  Graham Ce.  Chemonucleolysis: a double blind study comparing chemonucleolysis with intra discal hydrocortisone: in the treatment of backache and sciatica. , 1974 .

[32]  David P. Martin,et al.  Paralysis after transforaminal epidural injection and previous spinal surgery , 2004, Regional Anesthesia & Pain Medicine.

[33]  E. Buskens,et al.  Radiofrequency Denervation of Lumbar Facet Joints in the Treatment of Chronic Low Back Pain: A Randomized, Double-Blind, Sham Lesion-Controlled Trial , 2005, The Clinical journal of pain.

[34]  A. Mcgregor,et al.  Does the method of injection alter the outcome of epidural injections? , 2001, Journal of spinal disorders.

[35]  F. Phillips,et al.  Intradiscal Electrothermal Therapy Used to Manage Chronic Discogenic Low Back Pain: New Directions and Interventions , 2002, Spine.

[36]  B. Amor,et al.  Forceful epidural injections for the treatment of lumbosciatic pain with post-operative lumbar spinal fibrosis. , 1996, Revue du rhumatisme.

[37]  P. Gerszten,et al.  A prospective outcomes study of patients undergoing intradiscal electrothermy (IDET) for chronic low back pain. , 2002, Pain physician.

[38]  E. Buchser,et al.  Spinal Cord Stimulation for Chronic Back and Leg Pain and Failed Back Surgery Syndrome: A Systematic Review and Analysis of Prognostic Factors , 2005, Spine.

[39]  H. Breivik,et al.  [Epidural analgesia and epidural steroid injection for treatment of chronic low back pain and sciatica]. , 1979, Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke.

[40]  J. Ludwig,et al.  Lumbar epidural perineural injection: a new technique , 2005, European Spine Journal.

[41]  Lex M. Bouter,et al.  Conservative Treatment of Acute and Chronic Nonspecific Low Back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions , 1997, Spine.

[42]  G. Buttermann.  Treatment of Lumbar Disc Herniation : Epidural Steroid Injection Compared with Discectomy , 2004 .

[43]  R. Fraser.  Chymopapain for the Treatment of Intervertebral Disc Herniation The Final Report of a Double‐Blind Study , 1984, Spine.

[44]  R. Steffen,et al.  [Chemonucleolysis using chymopapain and collagenase. 3-year results of a prospective randomized study]. , 1992, Zeitschrift fur Orthopadie und ihre Grenzgebiete.

[45]  J. Shim,et al.  A Randomized Controlled Trial of Radiofrequency Denervation of the Ramus Communicans Nerve for Chronic Discogenic Low Back Pain , 2004, The Clinical journal of pain.

[46]  L. Bouter,et al.  Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials , 1995, Pain.

[47]  W. Hooten,et al.  Discitis after lumbar epidural corticosteroid injection: a case report and analysis of the case report literature. , 2006, Pain medicine.

[48]  J. Vital,et al.  [Comparative study of surgery and chemonucleolysis in the treatment of sciatica caused by a herniated disk]. , 1987, Acta orthopaedica Belgica.

[49]  W. Meyne,et al.  A systematic methodological review. Part 2: Validity , 2000 .

[50]  A. Martins,et al.  Double-blind evaluation of chemonucleolysis for herniated lumbar discs. Late results. , 1978, Journal of neurosurgery.

[51]  S. Hiller,et al.  A Controlled Study of Caudal Epidural Injections of Triamcinolone Plus Procaine for the Management of Intractable Sciatica , 1991, Spine.

[52]  P. Béliveau.  A comparison between epidural anaesthesia with and without corticosteroid in the treatment of sciatica. , 1971, Rheumatology and physical medicine.

[53]  J. Hirsch,et al.  Epidural steroids in the management of chronic spinal pain and radiculopathy. , 2003, Pain physician.

[54]  S. Piantadosi,et al.  Spinal Cord Stimulation versus Repeated Lumbosacral Spine Surgery for Chronic Pain: A Randomized, Controlled Trial , 2005, Neurosurgery.

[55]  S. Scheer,et al.  Randomized controlled trials in industrial low back pain relating to return to work. Part 2. Discogenic low back pain. , 1996, Archives of physical medicine and rehabilitation.

[56]  C. Masciocchi,et al.  Sciatica: treatment with intradiscal and intraforaminal injections of steroid and oxygen-ozone versus steroid only. , 2007, Radiology.

[57]  N. Bogduk,et al.  Two-year follow-up of a controlled trial of intradiscal electrothermal anuloplasty for chronic low back pain resulting from internal disc disruption. , 2002, The spine journal : official journal of the North American Spine Society.

[58]  A. Cats,et al.  Iliac crest pain syndrome in low back pain. A double blind, randomized study of local injection therapy. , 1991, The Journal of rheumatology.

[59]  J. Morris,et al.  Safety and efficacy of chymopapain (Discase) in the treatment of sciatica due to a herniated nucleus pulposus. Results of a randomized, double-blind study. , 1988, Spine.

[60]  Steven P. Cohen,et al.  Sacroiliac joint interventions: a systematic review. , 2007, Pain physician.

[61]  C. Graham.  Chemonucleolysis. A preliminary report on a double blind study comparing chemonucleolysis and intradiscal administration of hydrocortisone in the treatment of backache and sciatica. , 1975, The Orthopedic clinics of North America.

[62]  C. Cooper,et al.  A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. , 2005, Rheumatology.

[63]  M. van Kleef,et al.  Randomized Controlled Trial of Percutaneous Intradiscal Radiofrequency Thermocoagulation for Chronic Discogenic Back Pain: Lack of Effect From a 90-Second 70 C Lesion , 2001, Spine.

[64]  T. Thulbourne,et al.  Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain , 1992, Pain.

[65]  J. Hipp,et al.  Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. , 2006, Radiology.

[66]  L. Manchikanti,et al.  Medial branch neurotomy in management of chronic spinal pain: systematic review of the evidence. , 2002, Pain physician.

[67]  R. Deyo,et al.  Therapeutic Trials for Low Back Pain , 1994, Spine.

[68]  F. Frost,et al.  A CONTROL, DOUBLE-BLIND COMPARISON OF MEPIVACAINE INJECTION VERSUS SALINE INJECTION FOR MYOFASCIAL PAIN , 1980, The Lancet.

[69]  S. Hameroff,et al.  Comparison of Bupivacaine, Etidocaine, and Saline for Trigger‐Point Therapy , 1981, Anesthesia and analgesia.

[70]  J. Mathews,et al.  Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. , 1987, British journal of rheumatology.

[71]  C. Mulrow,et al.  Current methods of the US Preventive Services Task Force: a review of the process. , 2001, American journal of preventive medicine.

[72]  R. North,et al.  A prospective, randomized study of spinal cord stimulation versus reoperation for failed back surgery syndrome: initial results. , 1994, Stereotactic and functional neurosurgery.

[73]  P. Wolskee,et al.  Epidural morphine and methylprednisolone for low-back pain. , 1987, Anesthesiology.

[74]  Janna Friedly,et al.  Increases in Lumbosacral Injections in the Medicare Population: 1994 to 2001 , 2007, Spine.

[75]  C. Mar,et al.  Prolotherapy injections for chronic low-back pain. , 2007, The Cochrane database of systematic reviews.

[76]  L. Bouter,et al.  Epidural steroid injections for low back pain and sciatica: an updated systemtic review of randomized clinical trials , 1999 .

[77]  C. Slipman,et al.  A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain. , 2003, The spine journal : official journal of the North American Spine Society.

[78]  L. Manchikanti,et al.  Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: a randomized clinical trial. , 2001, Pain physician.

[79]  W. Hooten,et al.  Radiofrequency neurotomy for low back pain: evidence-based procedural guidelines. , 2005, Pain medicine.

[80]  Gogan Wj,et al.  Chymopapain. A 10-year, double-blind study. , 1992 .

[81]  J. Ioannidis,et al.  Better Reporting of Harms in Randomized Trials: An Extension of the CONSORT Statement , 2004, Annals of Internal Medicine.

[82]  J. Simmons,et al.  Intradiscal Steroids: A Prospective Double‐Blind Clinical Trial , 1992, Spine.

[83]  M. Picot,et al.  Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia – a prospective, randomised, double-blind study , 2003, Clinical Rheumatology.

[84]  D. Griffin,et al.  Epidural steroid injection for nerve root compression. A randomised, controlled trial. , 2005, The Journal of bone and joint surgery. British volume.

[85]  O. Tervonen,et al.  Periradicular Infiltration for Sciatica: A Randomized Controlled Trial , 2001, Spine.

[86]  P. Ravaud,et al.  Efficacy of epidural steroids in low back pain and sciatica. A critical appraisal by a French Task Force of randomized trials. Critical Analysis Group of the French Society for Rheumatology. , 1999, Revue du rhumatisme.

[87]  N. Bogduk.  Lumbar radiofrequency neurotomy. , 2006, The Clinical journal of pain.

[88]  P. Bezemer,et al.  Chemonucleolysis versus discectomy: a randomized multicenter trial. , 1989, Journal of neurosurgery.

[89]  F. Sturmans,et al.  Injection Therapy for Subacute and Chronic Benign Low Back Pain , 2001, The Cochrane database of systematic reviews.

[90]  D. Yates.  A comparison of the types of epidural injection commonly used in the treatment of low back pain and sciatica. , 1978, Rheumatology and rehabilitation.

[91]  David Sharp,et al.  The Use of Intradiscal Steroid Therapy for Lumbar Spinal Discogenic Pain: A Randomized Controlled Trial , 2004, Spine.

[92]  Salahadin Abdi,et al.  Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications. , 2005, Pain physician.

[93]  G. Waddell,et al.  Surgical interventions for lumbar disc prolapse. , 2007, The Cochrane database of systematic reviews.

[94]  E. Carragee,et al.  Low-Pressure Positive Discography in Subjects Asymptomatic of Significant Low Back Pain Illness , 2006, Spine.

[95]  J. Knottnerus,et al.  Conservative treatment of sciatica: a systematic review. , 2000, Journal of spinal disorders.

[96]  S. Carette,et al.  Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. , 1997, The New England journal of medicine.

[97]  R. Heary.  Intradiscal electrothermal annuloplasty: the IDET procedure. , 2001, Journal of spinal disorders.

[98]  Evans Jw.  SPECIAL" CALLS IN GENERAL PRACTICE. , 1963 .

[99]  R. Taylor.  Spinal cord stimulation in complex regional pain syndrome and refractory neuropathic back and leg pain/failed back surgery syndrome: results of a systematic review and meta-analysis. , 2006, Journal of pain and symptom management.

[100]  N. Chaudhary,et al.  The Efficacy of Corticosteroids in Periradicular Infiltration for Chronic Radicular Pain: A Randomized, Double-Blind, Controlled Trial , 2005, Spine.

[101]  W. T. Black.  Cases of Hepatitis, Dysentery, and Diarrhœa , 1852, Provincial medical & surgical journal.

[102]  M. Fukusaki,et al.  Symptoms of spinal stenosis do not improve after epidural steroid injection. , 1998, The Clinical journal of pain.

[103]  C. Bombardier,et al.  Minimal clinically important difference. Low back pain: outcome measures. , 2001, The Journal of rheumatology.

[104]  Mahmood Ahmad,et al.  The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations , 2007, Anesthesia and analgesia.

[105]  N. Sehgal,et al.  A systematic review of sacroiliac joint interventions. , 2005, Pain physician.

[106]  K. Malcolm Tillotson,et al.  Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation , 2000, European Spine Journal.

[107]  R. Deyo,et al.  Expenditures and health status among adults with back and neck problems. , 2008, JAMA.

[108]  Roger Chou,et al.  Surgery for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline , 2009, Spine.

[109]  N. Belmatoug,et al.  [Multicenter randomized double-blind study of triamcinolone hexacetonide versus chymopapain in the treatment of disk lumbosciatica. Initial results at 6 months]. , 1988, Revue du rhumatisme et des maladies osteo-articulaires.

[110]  L. Lenke,et al.  Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. , 2006, The Journal of bone and joint surgery. American volume.

[111]  Henry L. Lew,et al.  Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study. , 2008, Archives of physical medicine and rehabilitation.

[112]  A. Hedtmann,et al.  Chemonukleolyse mit Chymopapain und Kollagenase , 2008 .

[113]  C. Bombardier,et al.  Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. , 2000, Spine.

[114]  B. Walters,et al.  Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. , 2005, Journal of neurosurgery. Spine.

[115]  M. Runge,et al.  A Randomized, Double-Blind Study to Compare Low-Dose with Standard-Dose Chymopapain in the Treatment of Herniated Lumbar Intervertebral Discs , 1993, Spine.

[116]  B. Jabbari,et al.  A Focused Review of the Use of Botulinum Toxins for Low Back Pain , 2002, The Clinical journal of pain.

[117]  C. Silagy,et al.  A Meta-Analysis on the Efficacy of Epidural Corticosteroids in the Treatment of Sciatica , 1995, Anaesthesia and intensive care.

[118]  E. Kalso,et al.  Radiofrequency Denervation for Neck and Back Pain: A Systematic Review Within the Framework of the Cochrane Collaboration Back Review Group , 2003, Spine.

[119]  R A Deyo,et al.  Outcome Measures for Low Back Pain Research: A Proposal for Standardized Use , 1998, Spine.

[120]  J. Gibson,et al.  The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. , 1999, Spine.

[121]  P. van der Wurff,et al.  Clinical tests of the sacroiliac joint. , 2000, Manual therapy.

[122]  F. Falco,et al.  Paraplegia following a thoracolumbar transforaminal epidural steroid injection. , 2005, Pain physician.

[123]  R. Thisted,et al.  Safety and efficacy of chymopapain (Chymodiactin) in herniated nucleus pulposus with sciatica. Results of a randomized, double-blind study. , 1983, JAMA.

[124]  Watts Rw,et al.  A Meta-Analysis on the Efficacy of Epidural Corticosteroids in the Treatment of Sciatica: , 1995 .

[125]  B. Goldberger,et al.  Fatal case of BOTOX-related anaphylaxis? , 2005, Journal of forensic sciences.

[126]  C. Glynn,et al.  A double-blind comparison between epidural morphine and epidural clonidine in patients with chronic non-cancer pain , 1988, Pain.

[127]  G. Waddell,et al.  Surgery for Degenerative Lumbar Spondylosis: Updated Cochrane Review , 2005, Spine.

[128]  M. Brim,et al.  Chymodiactin Postmarketing Surveillance: Demographic and Adverse Experience Data in 29,075 Patients , 1984, Spine.

[129]  P. Lachenbruch.  Statistical Power Analysis for the Behavioral Sciences (2nd ed.) , 1989 .

[130]  Salahadin Abdi,et al.  Epidural steroids in the management of chronic spinal pain: a systematic review. , 2007, Pain physician.

[131]  C. Bombardier,et al.  A Critical Review of Reviews on the Treatment of Chronic Low Back Pain , 2001, Spine.

[132]  Y. Jeon,et al.  Spinal cord stimulation for chronic pain. , 2009, Annals of the Academy of Medicine, Singapore.

[133]  R. Fraser.  Chymopapain for the Treatment of Intervertebral Disc Herniation: A Preliminary Report of a Double‐Blind Study , 1982, Spine.

[134]  H. Weber,et al.  Double blind evaluation of extradural methyl prednisolone for herniated lumbar discs. , 1977, Acta orthopaedica Scandinavica.

[135]  D. Duncalf,et al.  Treatment of backache with spinal injections of local anesthetics, spinal and systemic steroids. A review , 1985, Pain.

[136]  H. Lew,et al.  Intradiscal Electrothermal Annuloplasty , 2005, American journal of physical medicine & rehabilitation.

[137]  R. Rothman,et al.  The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. , 1985, The Journal of bone and joint surgery. American volume.

[138]  L. Klenerman,et al.  Lumbar epidural injections in the treatment of sciatica. , 1984, British journal of rheumatology.

[139]  U. Oner,et al.  Epidural corticosteroid injection and amitriptyline for the treatment of chronic low back pain associated with radiculopathy , 2003 .

[140]  S. Winkler,et al.  Use of Epidural Corticosteroids in Low Back Pain , 2000, The Annals of pharmacotherapy.

[141]  G. Waddell,et al.  Surgery for degenerative lumbar spondylosis. , 2005, The Cochrane database of systematic reviews.

[142]  R. Rothman,et al.  The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. , 1985, The Journal of bone and joint surgery. American volume.

[143]  G. Lutz,et al.  Transforaminal Epidural Steroid Injections in Lumbosacral Radiculopathy: A Prospective Randomized Study , 2002, Spine.

[144]  E. M. Jensen,et al.  Injection of steroids and local anaesthetics as therapy for low-back pain. , 1985, Scandinavian journal of rheumatology.

[145]  N. Bogduk.  A narrative review of intra-articular corticosteroid injections for low back pain. , 2005, Pain medicine.

[146]  M. Leonardi,et al.  Intraforaminal O(2)-O(3) versus periradicular steroidal infiltrations in lower back pain: randomized controlled study. , 2005, AJNR. American journal of neuroradiology.

[147]  Jacob Cohen.  Statistical Power Analysis for the Behavioral Sciences , 1969, The SAGE Encyclopedia of Research Design.

[148]  W. Evans.  INTRASACRAL EPIDURAL INJECTION IN THE TREATMENT OF SCIATICA. , 1930 .

[149]  K. Knahr,et al.  Chemonucleolysis and automated percutaneous discectomy – a prospective randomized comparison , 2000, International Orthopaedics.

[150]  B. Eek,et al.  A NEW APPROACH TO THE TREATMENT OF CHRONIC LOW BACK PAIN , 1987, The Lancet.

[151]  C. Aprill,et al.  Lumbosacral epidural steroid injections. , 2000, Archives of physical medicine and rehabilitation.

[152]  A. Kirkpatrick.  The use of epidural steroids in the treatment of lumbar radicular pain. , 1990, The Journal of bone and joint surgery. American volume.

[153]  J. Gibson,et al.  Surgery for lumbar disc prolapse. , 2000, The Cochrane database of systematic reviews.

[154]  H. Yuan,et al.  Chymopapain chemonucleolysis in lumbar disk disease. , 1975, JAMA.

[155]  E. Kalso,et al.  Radiofrequency denervation for neck and back pain. A systematic review of randomized controlled trials. , 2003, The Cochrane database of systematic reviews.

[156]  V. Mooney,et al.  A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain. , 1993, Journal of spinal disorders.

[157]  C. Kallenberg.  CYCLOPHOSPHAMIDE AND SUPPRESSOR CELL FUNCTION , 1981, The Lancet.

[158]  J. Skinner,et al.  Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. , 2006, JAMA.

[159]  A. Varma,et al.  Double-Blind Evaluation of Collagenase Injections for Herniated Lumbar Discs , 1984, Spine.

[160]  J. Gallagher.  Radiofrequency facet joint denervation in the treatment of low back pain : a prospective controlled doubleblind study to assess its efficacy , 1994 .

[161]  S. Wiesel,et al.  A Prospective, Randomized, Double-Blind Evaluation of Trigger-Point Injection Therapy for Low-Back Pain , 1989, Spine.

[162]  H. Hefter,et al.  Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport®) for the relief of upper back myofascial pain syndrome: Results from a randomized double-blind placebo-controlled multicentre study , 2006, Pain.

[163]  C. Slipman,et al.  A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. , 2005, Archives of physical medicine and rehabilitation.

[164]  S. Hassenbusch,et al.  Treatment of Chronic Pain in Failed Back Surgery Patients with Spinal Cord Stimulation: a Review of Current Literature and Proposal for Future Investigation , 2000, Neuromodulation : journal of the International Neuromodulation Society.

[165]  M. Bhandari,et al.  Assessing Observational Studies of Spinal Fusion and Chemonucleolysis , 2003, Spine.

[166]  P. Myllynen,et al.  Chronic Unilateral Low-Back Pain: Predictors of Outcome of Facet Joint Injections , 1990, Spine.

[167]  N. Sehgal,et al.  A systematic review of therapeutic facet joint interventions in chronic spinal pain. , 2007, Pain physician.

[168]  R. Grahame,et al.  Extradural corticosteroid injection in management of lumbar nerve root compression. , 1974, British medical journal.

[169]  Y. Maugars,et al.  Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study. , 2000, Joint, bone, spine : revue du rhumatisme.

[170]  G. Guyatt,et al.  Validation of an index of the quality of review articles. , 1991, Journal of clinical epidemiology.

[171]  H. Bozkuş,et al.  Radiofrequency Lesioning Using Two Different Time Modalities for the Treatment of Lumbar Discogenic Pain: A Randomized Trial , 2003, Spine.

[172]  J. Laredo,et al.  Automated Percutaneous Lumbar Discectomy Versus Chemonucleolysis in the Treatment of Sciatica: A Randomized Multicenter Trial , 1993, Spine.

[173]  G. Rolly,et al.  Nerve root sleeve injections in patients with failed back surgery syndrome: a comparison of three solutions. , 1999, The Clinical journal of pain.

[174]  B. Koes,et al.  Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review , 2007, European Spine Journal.

[175]  H. Droller.  PHARMACOKINETICS OF INHALATIONAL ANAESTHETICS. , 1964, Lancet.

[176]  Andrea Furlan,et al.  Updated Method Guidelines for Systematic Reviews in the Cochrane Collaboration Back Review Group , 2003, Spine.

[177]  J. Webb,et al.  A Comparison of Surgery and Chemonucleolysis in the Treatment of Sciatica A Prospective Randomized Trial , 1984, Spine.

[178]  L. Lenke,et al.  The Effect of Nerve-Root Injections on the Need for Operative Treatment of Lumbar Radicular Pain: A Prospective, Randomized, Controlled, Double-Blind Study* , 2000, The Journal of bone and joint surgery. American volume.

[179]  N. Bogduk,et al.  A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. , 2003, The spine journal : official journal of the North American Spine Society.

[180]  L. Manchikanti,et al.  ASSESSMENT: USE OF EPIDURAL STEROID INJECTIONS TO TREAT RADICULAR LUMBOSACRAL PAIN: REPORT OF THE THERAPEUTICS AND TECHNOLOGY ASSESSMENT SUBCOMMITTEE OF THE AMERICAN ACADEMY OF NEUROLOGY , 2007, Neurology.

[181]  P. Glasziou,et al.  Prolotherapy Injections, Saline Injections, and Exercises for Chronic Low-Back Pain: A Randomized Trial , 2004, Spine.

[182]  P. Guggenbuhl,et al.  Forceful sacrococcygeal injections in the treatment of postdiscectomy sciatica. A controlled study versus glucocorticoid injections. , 2001, Joint, bone, spine : revue du rhumatisme.

[183]  M. Sekiguchi,et al.  Do Corticosteroids Produce Additional Benefit in Nerve Root Infiltration for Lumbar Disc Herniation? , 2008, Spine.

[184]  F. Rubenthaler,et al.  Five-Year Results From Chemonucleolysis With Chymopapain or Collagenase: A Prospective Randomized Study , 2001, Spine.

[185]  R. Mollan,et al.  A Prospective Randomized Trial of Chemonucleolysis and Conventional Disc Surgery in Single Level Lumbar Disc Herniation , 1992, Spine.

[186]  G. Andersson,et al.  Meta-analysis of the efficacy and safety of intradiscal electrothermal therapy (IDET). , 2006, Pain medicine.

[187]  R A Deyo,et al.  The importance of placebo effects in pain treatment and research. , 1994, JAMA.

[188]  Peter Croft,et al.  Interpreting Change Scores for Pain and Functional Status in Low Back Pain: Towards International Consensus Regarding Minimal Important Change , 2008, Spine.

[189]  A. Moore,et al.  Epidural steroids for sciatica. , 1996, Anaesthesia and intensive care.

[190]  Joon Woo Lee,et al.  Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. , 2007, Radiology.

[191]  S. Lipson,et al.  Epidural steroids, epidural morphine and epidural steroids combined with morphine in the treatment of post-laminectomy syndrome , 1989, Pain.

[192]  P. Herberts,et al.  Surgery versus chemonucleolysis for herniated lumbar discs. A prospective study with random assignment. , 1983, Clinical orthopaedics and related research.

[193]  H. D. de Vet,et al.  Injection therapy for subacute and chronic low-back pain. , 2008, The Cochrane database of systematic reviews.

[194]  B. Jabbari,et al.  Botulinum toxin A and chronic low back pain , 2001, Neurology.

[195]  M. van Kleef,et al.  Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. , 1999, Spine.

[196]  E. Buskens,et al.  Radiofrequency lesioning of dorsal root ganglia for chronic lumbosacral radicular pain: a randomised, double-lind, controlled trial , 2003, The Lancet.

[197]  G. Buttermann.  The effect of spinal steroid injections for degenerative disc disease. , 2004, The spine journal : official journal of the North American Spine Society.

[198]  P. L. Day.  Early, interim and long term observations on chemonucleolysis in 876 patients with special comments on the lateral approach. , 1974, Clinical orthopaedics and related research.

[199]  S. Rozenberg.  Glucocorticoid therapy in common lumbar spinal disorders. , 1998, Revue du rhumatisme.

[200]  R. Marcus,et al.  Effect of Autologous Blood Donation in Patients Undergoing Elective Spine Surgery , 1992, Spine.

[201]  M. Brown,et al.  Chemonucleolysis (Discolysis) with Collagenase , 1986, Spine.

[202]  T. Albert,et al.  Differences in the Work-Up and Treatment of Conditions Associated With Low Back Pain by Patient Gender and Ethnic Background , 2005, Spine.

[203]  M. Rossignol,et al.  Radiofrequency Facet Joint Denervation in the Treatment of Low Back Pain: A Placebo-Controlled Clinical Trial to Assess Efficacy , 2001, Spine.

[204]  Graham Ce.  Chemonucleolysis. A preliminary report on a double blind study comparing chemonucleolysis and intradiscal administration of hydrocortisone in the treatment of backache and sciatica. , 1975 .

[205]  S. Arrigain,et al.  Intradiscal thermal annuloplasty versus intradiscal radiofrequency ablation for the treatment of discogenic pain: a prospective matched control trial. , 2005, Pain medicine.

[206]  Epidural injections of indomethacin for postlaminectomy syndrome: a preliminary report. , 2003, Anesthesia and analgesia.