1. 2009;12;207-232Systematic Review of the Effectiveness of Thermal Annular Procedures in Treating Discogenic Low Back Pain
   Systematic Review
   Salim M. Hayek, MD, PhD, Standiford Helm II, MD, Ramsin M. Benyamin, MD, and Laxmaiah Manchikanti, MD.

BACKGROUND: Chronic discogenic low back pain is a common problem with significant personal and societal costs. Thermal annular procedures (TAPs) have been developed in an effort to provide a minimally invasive treatment for this disorder. Multiple techniques utilized are intradiscal electrothermal therapy (IDET), radiofrequency annuloplasty, and intradiscal biacuplasty (IDB). However, these treatments continue to be controversial, coupled with a paucity of evidence.

STUDY DESIGN: A systematic review of the literature evaluating the efficacy or effectiveness of TAPs.

OBJECTIVE: To determine the effectiveness of TAPs in reducing low back pain in patients with intradiscal disorders.

METHODS: A comprehensive evaluation of the literature relating to TAPs was performed. The literature was evaluated according to Cochrane Review criteria for randomized controlled trials (RCTs) and according to the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies.

The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, and return to work.

Data sources included relevant literature of the English language identified through searches of PubMed, EMBASE, the Cochrane Library, and the Database of Reviews of Effectiveness (DARE).

OUTCOME MEASURES: Short-term effectiveness was defined as one-year or less and long-term effectiveness was defined as greater than one-year.

RESULTS: Systematic review of IDET identified 2 RCTs and 16 observational studies with an indicated evidence of Level II-2.

Systematic review of radiofrequency annuloplasty identified no RCTs but 2 observational studies with an uncertain evidence of Level II-3.

Systematic review of IDB identified one pilot study. The level of evidence is lacking with Level III.

LIMITATIONS: The limitations of this review include paucity of the literature and lack of evidence with internal validity and generalizability.

CONCLUSION: IDET offers functionally significant relief in approximately one-half of appropriately chosen chronic discogenic low back pain patients. There is minimal evidence supporting the use of radiofrequency annuloplasty and IDB.