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continuous gentle movement. Rising in the morning is difficult because of pain and stiffness, which ease as physical activity increases. When rest is unavoidable, pain is commonly reduced by the position of lumbar flexion, backward bending is restricted by pain; forward bending is usually of normal range and character, with little or no pain. This is a lumbar facet syndrome. They describe all of their patients treated with posterolateral and intertransverse fusion operations, with some patients fused from L2 to the sacrum.
Varnvanij, at al., in 1998 discussed the surgical treatment for internal disc disruption is treated with spinal fusion. The patients who achieved successful lumbar fusion had a better clinical outcome and better chance of work resumption. They stated that internal disc disruption, a clinical syndrome introduced by Crock in 1970, has been recognized as one of the major causes of chronic low back pain. The diagnosis is confirmed by provocative discography reproducing concordant pain. The surgical treatment is advocated only when conservative management fails.
Parker, et al., in 1995 concluded that posterolateral intertransverse fusion could be used to successfully manage chronic discogenic back pain. They stated that surgeons have treated discography/discogenic pain with fusions since 1980. These authors have used interbody fusion, anterior, posterior or circumferential. They reported that the numbers of levels fused did not affect outcome.
Hacker in 1997 states that if there are adjacent level abnormalities these need to be treated as well, and if they are not treated, this seriously affects the outcome of the index procedure.
Schwarzer, et al., showed that between 30% and 50% of patients with refractory low back pain suffer from internal disc disruption, yet have negative neurological examinations. Provocative discography is valuable in determining whether a disc accounts for disabling low back pain. Successful surgical treatment based on lumbar provocative discography has been documented in other series.
Coihoun, et al., reported 88% of their patients had satisfactory results for lumbar fusion based on discography.
Bogduk and Toomey in 1991 and Friberg in 1954 demonstrated that less than 30% of low back problems legitimately could be ascribed to nerve root compression. Others reported strong correlations between outer annulus disruption and pain reproduction on discography.
A paper by Braithwaite in 1998 demonstrated that modic changes (Continued on page 70)
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