Mario Muto Cosma Andreula and Marco Leonardi

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Low back pain and nerve root pain are among the most common conditions affecting the lumbar spine. Approximately 80% of the population in western countries will experience one or more episodes of low back pain in their lifetime, and 55% will suffer from low back pain associated with a radicular component.1

Back pain is commonly caused by disc disease; however, other factors may be responsible for nerve root syndromes, and these should be considered when clinical symptoms fail to match computed tomography (CT) findings.2

We know from the natural history of a herniated disc that clinical symptoms tend to resolve in up to 50% of patients and the disc herni-ation can shrink on follow-up CT or magnetic resonance (MR) scans within 8 or 9 months of the start of back pain.1-3

The short-term success rate after surgery for lumbosacral disc her-niation is estimated at 95%, with a 2 to 6% incidence of true recurrence of herniation. The success rate drops to 80% over time owing to the onset of symptoms linked to failed back surgery syndrome (FBSS), a condition characterized by recurrence of disc herniation and/or hypertrophic scarring with severe symptoms in 20% of patients.4-5

The failures after back surgery have stimulated research into new techniques to improve patient outcome. At the same time, advances in percutaneous techniques by interventional procedures [chemodiscoly-sis with chymopapain, aspiration of the nucleus according to Onik (see Chapter 8), intradiscal electrothermal annuloplasty (IDET), discectomy laser, nucleoplasty, etc.) have minimized the invasive nature of surgery and have avoided complications such as scarring and infection associated with open surgery.

Reducing intervertebral disc size by mechanical aspiration of disc fragments, by chemical dissolution, or by drying can reduce the conic pressure on the torn annulus and create the space necessary for disc retraction.

All percutaneous procedures are mildly invasive, requiring only a short hospital stay. By avoiding the spinal canal, these techniques also eliminate the risk of postoperative scarring that has been associated with surgery. Scarring is often responsible for recurrence of pain. Percutaneous techniques can also be repeated in the same patient without eliminating the option of traditional surgery. The success rates reported with chemonucleolysis and aspiration vary from 65 to 80% with excellent or good results.4

Epidural steroid injections under CT or fluoroscopic guidance may also be used to minimize radicular pain.6-11

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