1. 2017;20;447-470Effectiveness of Thermal Annular Procedures in Treating Discogenic Low Back Pain
   Systematic Review
   Thomas T. Simopoulos, MD, Salahadin Abdi, MD, PhD, Mohamed Ahamed El Terany, MD, Milan Stojanovic, MD, and Standiford Helm II, MD.

BACKGROUND: Discogenic low back is a distinct clinic entity characterized by pain arising from a damaged disc. The diagnosis is clouded by the controversy surrounding discography. The treatment options are limited, with unsatisfactory results from both conservative treatment and surgery. Multiple interventional therapies have been developed to treat discogenic pain, but most have not yet been validated by high quality studies.

The best studied treatment for discogenic pain is the use of heat, which has been labeled as thermal intradiscal procedures (TIPs) by the Centers for Medicare and Medicaid Services (CMS). As the pathology is located in the annulus, we use the term thermal annular procedures (TAPs).

OBJECTIVES: The aim of this study is to evaluate and update the efficacy of TAPs to treat chronic refractory discogenic pain.

STUDY DESIGN: The design of this study is a systematic review.

METHODS: The available literature on TAPs in treating chronic refractory discogenic pain was reviewed. The quality of each article used in this analysis was assessed.

The level of evidence was classified on a 5-point scale from strong, based upon multiple randomized controlled trials (RCTs) to weak, based upon consensus, as developed by the US Preventive Services Task Force (USPSTF) and modified by the American Society of Interventional Pain Physicians (ASIPP).

Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2015 and manual searches of the bibliographies of known primary and review articles.

The primary outcome measures were pain relief and functional improvement of at least 40%.

Short-term efficacy was defined as improvement for less than 6 months; long-term efficacy was defined as improvement for 6 months or more.

RESULTS: For this systematic review, 49 studies were identified. Of these, there were 4 RCTs and no observational studies which met the inclusion criteria.

Based upon 2 RCTs showing efficacy, with no negative trials, there is Level I, or strong, evidence of the efficacy of biacuplasty in the treatment of chronic, refractory discogenic pain.

Based upon one high-quality RCT showing efficacy and one moderate-quality RCT interpreted as showing no benefit, there is Level III, or moderate, evidence supporting the use of intradiscal electrothermal therapy (IDET) in treating chronic, refractory discogenic pain.

The evidence supporting the use of discTRODE is level V, or limited.

CONCLUSION: The evidence is Level I, or strong, that percutaneous biacuplasty is efficacious in the treatment of chronic, refractory discogenic pain. Biacuplasty may be considered as a first-line treatment for chronic, refractory discogenic pain.
The evidence is Level III, or moderate, that IDET is efficacious in the treatment of chronic, refractory discogenic pain.

The evidence is Level V, or limited, that discTRODE is efficacious in the treatment of chronic, refractory discogenic pain.

Key words: Spinal pain, chronic low back pain, intradiscal disorder, IDET, biacuplasty, discTRODE, thermal intradiscal disorders, thermal annular disorders