Introduction

The indications for surgical management of compressive syndromes such as herniated nucleus pulposus with radiculopathy and lumbar spinal stenosis with neuroclaudication are clear. Predictable outcomes from decompression to alleviate referred extremity pain may be obtained in a high percentage of patients. For example, in the case of a herniated nucleus pulposus with unilateral radiculopathy, assuming strict concordance between the patient's clinical presentation and imaging findings, a 90 to 100% successful outcome is expected following laminotomy discectomy.1 Likewise, the addition of arthrodesis to treat degenerative spondylolisthesis in the setting of stenosis with neuroclaudication has been shown to be the treatment of choice, based on randomized prospective data.2 Outcome data for surgical treatment of back pain per se, in the absence of neural compression and referred extremity pain, is, however, less promising.3,4 Lumbar discography, for example, has been cited as a reasonable diagnostic technique to identify painful segments and treat them by arthrodesis.3 Not only have the sensitivity and specificity of the diagnostic technique been criti-cized,5-7 however, but the treatment itself—arthrodesis—has been studied in only one randomized, prospective study to date.8

From a surgical perspective, precise, reliable, sensitive, and specific diagnostic techniques are required to identify a lesion amenable to surgical decompression, and/or reconstruction. Controversy surrounding each step of a treatment algorithm such as that just described (e.g., persistent axial pain ^ discography ^ arthrodesis) and conflicting or variable reports of sensitivity, specificity, and efficacy further hinder the clinician in making rational decisions based on acceptable standards of care or scholarly consensus. Invariably, individual surgical philosophy plays a role in patient selection, with some physicians more likely to recommend surgery for indications that would not be accepted by others.4,9 Furthermore, a surgical diagnosis may not represent a true surgical lesion. It is the unfortunate experience of many surgeons to have patients referred to them with a lumbar disc prolapse, apparent radiculopathy, and the expectation of a surgical recommendation, to discover that the prolapse demonstrated on magnetic resonance imaging or computed tomographic myography is minimal, or is not precisely correlated with the patient's symptoms.

The surgical treatment of lumbar spinal stenosis serves as another example. In one report, patients with a higher degree of midsagittal stenosis including complete myelographic block had lower functional disability scores at follow-up of 4.5 years. Patients who had a mid-sagittal stenosis exceeding 12 mm had a poor outcome.10 While one surgeon may wish to treat a patient conservatively until such a critical threshold is reached, to maximize surgical outcome, another may offer an earlier decompression based on individual patient characteristics, experience, and expectations. This difference in philosophy may be further compounded by discrepancies in education between patient and physician and, thus, in their respective expectations.

Another level of variance is added by pain-based diagnostics, which contains an unavoidable element of subjectivity. Obviously, patient expectations factor into this as well, with most surgeons more likely to offer surgical care to those who appear to have reasonable expectations. Unfortunately, there are no reproducible standards whereby patient expectations can be quantified,1114 thus adding another layer of individual idiosyncrasy.

The goals of this chapter are to review from a surgeon's perspective provocative diagnostic maneuvers, including discography, facet blockade, selective nerve root blockade, epidural infusion, and sacroiliac joint injection. Specifically, the results of these diagnostic maneuvers will be scrutinized for their predictive value with regard to current concepts in surgical treatment. Additionally, vertebroplasty and kypho-plasty will be reviewed, as well as intradiscal therapy, focusing specifically on intradiscal electrothermal therapy (IDET).

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