Lee Wolfer

Comparison of growth factor and cytokine expression in patients with degenerated disc disease and herniated nucleus pulposus

OBJECTIVES This study was conducted to investigate the expression of cytokines and growth factors in disc specimens obtained from patients with herniated nucleus pulposus (HNP) and degenerated disc disease (DDD). DESIGN AND METHODS MRI and Western blot analyses were performed to evaluate the levels of disc degeneration and the expression levels of cytokines and growth factors. RESULTS The levels of TNF-alpha and IL-8 were significantly greater in the DDD group than in the HNP group, but no statistical differences were observed in the expression of IL-1beta, IL-6 and IL-12 between the HNP and DDD groups. In addition, the expression of TGF beta, VEGF and NGF was significantly higher in the DDD group than in the HNP group. CONCLUSION The greater levels of cytokine and growth factor expression in the DDD group than in the HNP explain why discogenic patients usually have more severe back pain than patients with herniated discs.

Are Outer Annular Fissures Stimulated During Diskography the Source of Diskogenic Low-Back Pain? An Analysis of Analgesic Diskography Data

OBJECTIVE This study aimed to clarify whether painful annular fissures stimulated during provocation diskography are the likely source of diskogenic pain. DESIGN A retrospective analysis was conducted of prospectively collected data. SETTING Multidisciplinary, academic spine center. PATIENTS The study was completed in a cohort of 28 consecutive patients were enrolled presenting with 6 months duration of axial low-back pain recalcitrant to physical therapy, oral analgesics, and epidural steroid injections and who have diskogenic pain based on history, exam, magnetic resonance imaging, and diskography. INTERVENTIONS Subjects underwent provocation diskography and analgesic diskography utilizing a balloon-tipped intradiskal catheter allowing intradiskal injection of anesthetic. OUTCOME MEASURES Visual analog scale, finger-to-floor distance were utilized as outcome measures. RESULTS 80% of painful intervertebral disks as detected by provocation diskography were sufficiently anesthetized resulting in >50% reduction in low-back pain during analgesic diskography. CONCLUSION Diskogenic pain is in varying degrees caused by the sensitized nociocepters within annular tears.

Spine Injections for Persistent Lumbar and Radicular Pain After Lumbar Spine Surgery

The goal of this chapter is to inform the reader about the most common spine injections currently used to diagnose and treat post-lumbar surgery syndrome (PLSS). Due to the influence of payors and policymakers on surgical decision-making, PLSS will also be briefly presented within an epidemiologic, historic, and socioeconomic context. Payors, policymakers, researchers, and other stakeholders have sounded an “alarm” over the increase in spine surgeries. They have sounded the same alarm over the proliferation of interventional procedures in nonoperative spine practices. Detractors argue that some of these procedures are dubious, risky, and scientifically unproven and do not lead to long functional improvement. Some interventions have stood the test of time, e.g., epidural injections, diagnostic facet and sacroiliac joint blocks, and medial branch neurotomy, but other treatments such as pulsed radiofrequency treatments of spinal nerves or various intradiscal therapies are recent interventions and may or may not be in common use in the future. With the meteoric rise in spine injections over the last decade, often without appropriate indications, spine interventionalists have come under intense scrutiny to justify the medical necessity of their procedures. Ultimately, both patient and the physician are the losers with performance of medically unnecessary spine injections. Because spine interventionalists did not utilize rigorous indications for successful diagnostic and therapeutic interventions in the last decade, payors and policymakers intervened.