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Lumbar spine pain originating from vertebral osteophytes
Regional Anesthesia and Pain Medicine 24(4): 347-351, 1999
Case Reports Lumbar Spine Pain Originating From
Vertebral Osteophytes Tim J. Lamer, M.D.
Background and Objectives. Axial spine pain originates from a number of structures.
Putative pain generators include facet joints, intervertebral disks, sacroiliac joints, and myofascial structures. Osteophytes originating from lumbar vertebral bodies in the area of the intervertebral disks may be a source of nociceptive low back pain which may respond to local injection. Methods. Five patients with axial low back pain unresponsive to traditional treatment modalities were treated with fluoroscopic guided injection of local anesthetic and corticosteroid near large intervertebral osteophytes. Results. All 5 patients experienced relief. Conclusion. Vertebral osteophytes may be a source of axial spine pain. Injection of painful osteophytes with a local anesthetic and corticosteroid solution may produce pain relief. Reg Anesth Pain Med 1999: 24: 347351.
Key words: back pain, vertebral osteophyte, spine injection.
Methods
Nociceptive axial spine pain m a y originate from several sources including facet joints, intervertebral disks, sacroiliac joints, and myofascial structures (1). Traditional therapies include therapeutic exercise, physical modalities (heat, ice, electrical stimulation), a n t i n f l a m m a t o r y drugs, and local injections. This report describes five patients with extensive degenerative spine arthritis and large vertebral osteophytes w h o obtained relief from fluoroscopic-guided injection of the osteophytes with a local anesthetic-corticosteroid solution after failing to improve from traditional m a n a g e m e n t techniques.
Five patients with axial low back pain were treated with one or m o r e osteophyte injections. Two patients had unilateral osteophytes at one vertebral level, two patients had bilateral osteophytes at one vertebral level, and one patient had unilateral osteophytes at two adjacent vertebral levels. All of the patients presented with nonradicular, axial low back pain, n o r m a l neurologic examination, and lumbar spine radiographs demonstrating extensive degenerative joint disease of the lumbar spine. The patients were treated initially with an e x t e n d e d course of m o r e traditional therapeutic interventions including nonsteroidal antinflammatory drugs (NSAIDs), oral opioids, epidural and facet injections, and therapeutic exercise u n d e r the guidance of a physiatrist. After failing to respond to these interventions, the patients were treated with local osteophyte injection. After the initial injection, all the patients were followed for an e x t e n d e d period of time. If the patient experienced recurrent pain following a period of pain relief, the injection was repeated. The
From the Division ot Pain Medicine, Mayo Clinic Jacksonville, Jacksonville, Florida. Accepted for publication March 19, 1999. Reprint requests: Tim J. Lamer, M.D., Division of Pain Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224. Copyright © 1999 by the American Society of Regional Anesthesia. 0146-521X/99/2404-001255.00/0
347
348
Regional Anesthesia and Pain Medicine Vol. 24 No 4 July-August 1999
interval between injections was determined by the duration of pain relief after each injection. The technique was performed with the patients placed in the prone position on a fluoroscopy table. Preinjection localization of the needle entry site(s) was performed with fluoroscopy. The needle entry site was 6 - 7 cm from the midline in all cases. An oblique approach similar to the technique used to perform lumbar sympathetic block was used. After local anesthesia of the skin and deeper tissues was placed, a 22-gauge, 15-cm needle was advanced using fluoroscopic guidance, until it contacted the hypertrophic osteophyte(s) which were typically located at the anterolateral aspect of the disks in all cases. Lateral, oblique, and posteroanterior (PA) fluoroscopy and injection of 0.5-1.0 mL ot iopamidol contrast was used to confirm needle placement at the tip of the protruding osteophyte and spread of injectant around the area of the osteophyte (Fig. 1, 2A-C). In all cases, 1.0 mL was sufficient to cover the affected area. This was followed by injection of 2-3 mL lidocaine (0.5-1%) plus a corticosteroid suspension (6 mg betamethasone or 40 mg triamcinolone) at each osteophyte.
Case Report A 62-year-old male presented with a history of axial, nonradicular low back pain of several years duration. His pain was worse with bending and twisting activities, was localized to the right lower lumbar paraspinal area, and had an average pain intensity of 8/10. Previous treatments including multiple NSAIDs, electrical stimulation, therapeutic exercise, and epidural and facet injections were not beneficial. Physical examination revealed normal lower extremity strength, sensation, and symmetric deep tendon reflexes. Straight leg raising was negative for radicular pain. There was minimal paraspinal tenderness, and he experienced reproduction of his pain with lateral bending toward the right side. Lumbar spine radiographs revealed extensive degenerative disk and facet disease. Flexion-extension and lateral bending films did not demonstrate excessive movement. Magnetic resonance imaging with and without gadolinium revealed degenerative disks and facets at multiple lumbar levels-most pronounced at L4-LS. There was advanced degenerative disk disease at L4-L5 with a large anterior osteophyte. An initial osteophyte injection at L4-L5 on the right resulted in significant improvement with a post-injection pain score of 4/10. A repeat injection 1 month later resulted in more improvement, with a pain score of 2/10. In addition, the patient was able to resume playing golf. The patient has been seen for 3 years and receives two to three injections per year. He typically experiences 2-3 months of excellent relief followed by a gradual increase in symptoms leading up to the next injection. He has remained very active, continuing to work and play golf.
Results
Fig. 1. Image obtained from fluoroscopic-guided needle placement for osteophyte injection. Arrows identify the radiopaque contrast, which has spread between the L4 and S1 vertebral osteophytes.
All five patients had significant improvement following the injection, with postinjection pain scores decreasing by 50% or more. All patients had recurrent pain and required one or more repeat injections (Table 1). One patient received four injections, each time experiencing pain relief but only for the duration of the local anesthesia. The injections were discontinued because of a lack of a long-term response, and the patient was treated with opioid medications. Two patients had sufficient relief following a series of injections that they did not require repeat injections. Two patients experienced extended relief and continue to be seen periodically for reinjection (two to three times
Lumbar Spine Pain from Vertebral Osteophytes
•
Lamer 349
Fig. 2. (A) Posteroanterior view of needle placement at the tip of an L4-L5 osteophyte. (B) Oblique view of the same needle placement at L4-L5. (C) Spread of contrast injected through same needle seen in Fig. 2B. The contrast has spread around the protruding tip of the osteophyte. The small arrows outline the L5-S1 facet joint.
per year). No complications attributed to the procedure were identified.
Discussion Nociceptive spine pain m a y originate f r o m several musculoskeletal structures (Table 2). Traditional therapeutic interventions for musculoskeletal low back pain typically consist of one or m o r e of the following: oral medications, physical modalit~es, and t h e r a p e u t i c exercise (2,3). A l t h o u g h the role of
facet, myofascial trigger point, sacroiliac, intradiscal, and epidural injections are controversial, properly selected patients m a y benefit f r o m such treatment. The c o n c e p t of v e r t e b r a l o s t e o p h y t e s as a source of n o c i c e p t i v e p a i n a n d t r e a t m e n t w i t h injection t h e r a p y is n o t well described. F r y m o y e r et al. d e m o n s t r a t e d a c o r r e l a t i o n b e t w e e n the p r e s e n c e of l u m b a r v e r t e b r a l o s t e o p h y t e s a n d sev e r e l o w b a c k p a i n a n d l o w e r e x t r e m i t y p a i n (4). It is u n c l e a r w h y s o m e p a t i e n t s d e v e l o p t h e s e o s t e o p h y t e s , a n d in t h o s e t h a t h a v e t h e m , it is
350
Regional Anesthesia and Pain Medicine Vol. 24 No. 4 July-August 1999 Table 1. Results of Osteophyte Injection
Preinjection Pain Score
Patient
Site
67 male 76 male
Right L4-L5 Right L3-L4 Left L4-L5 Right L4-L5 Bilateral L4-L5 Bilateral L4-L5
62 male 71 male 68 male
Postinjection Pain Score
Total Follow-up Period (months)
Total No. Injections
Outcome
8/10
2/10
24
3
A*
8/10 8/10 5-8/10 8/10
3/10 4/10 0 4/10
12 36 12 3
6 6 2 4
By By A* C*
* Resolution of pain. t Extended pain relief: periodic reinjection required. ~ Relief for duration of local anesthetic only.
u n c l e a r w h y some cause pain a n d some do not. The p a t h o p h y s i o l o g i c events leading to the form a t i o n of these large o s t e o p h y t e s is n o t k n o w n . The relief of pain following injection w i t h local anesthetic, t h o u g h n o t absolutely diagnostic, is o n e piece of evidence that vertebral o s t e o p h y t e s m a y be a source of pain. The limitations of diagnostic a n d t h e r a p e u t i c inferences m a d e by observing the response to local anesthetic blocks are well r e c o g n i z e d (5). Pain relief following local blocks m a y result f r o m the t h e r a p e u t i c effect of the block, a systemic effect of the injectant(s), spread of the injectant to adjacent structures (e.g., n e r v e root, s y m p a t h e t i c trunk, or gray rami c o m m u n i c a n s ) , or a placebo response. Despite these limitations, carefully controlled fluoroscopic guided injections c u r r e n t l y are the best diagnostic test to d e t e r m i n e the source of pain in patients w i t h axial spine pain as it has b e e n d e m o n s t r a t e d that h i s t o r y a n d physical e x a m i n a tion are unreliable in localizing the source of pain (6). All five of the patients described in this series h a d extensive p r e v i o u s t r e a t m e n t including epidural steroid injections, w i t h o u t i m p r o v e m e n t , w h i c h suggests but does n o t p r o v e that placebo response, adjacent spread, a n d systemic effects w e r e n o t o p e r a n t in the patients described here. In all five cases, the injection was p e r f o r m e d w i t h
the needle placed at the m o s t p r o t u b e r a n t tip of the o s t e o p h y t e , d e t e r m i n e d f r o m PA, lateral, a n d oblique fluoroscopic images. A small a m o u n t of contrast dye c o n f i r m e d spread of the injection a r o u n d the area of the o s t e o p h y t e a n d lack of spread far b e y o n d the target. In n o case was t h e r e spread to the intervertebral f o r a m e n , facet joint, or epidural space. These injections are performed to deposit the injectant a r o u n d the tip of the protruding osteophyte. On occasion, some injectant will spread b e t w e e n the osteophytic c o m p o n e n t s from the two vertebrae involved (Fig. 1). This is not related in a n y w a y to provocative discography in w h i c h a needle is placed into the center of the disk and contrast or other material is injected.
Conclusion A variety of structures m a y c o n t r i b u t e to nociceptive low back pain. Patients w i t h back pain a n d the presence of large l u m b a r spine osteop h y t e s w h o do n o t r e s p o n d to traditional t h e r a peutic m e a s u r e s m a y be candidates for injection of the o s t e o p h y t e ( s ) w i t h a local a n e s t h e t i c - c o r ticosteroid solution.
Table 2. Putative Sources of Musculoskeletal Low Back Pain
Structure Structures innervated by branches from ventral rami Intervertebral disk Anterior and posterior longitudinal ligaments Psoas and quadratus lumborum muscles Structures innervated by branches from dorsal rami Facet (zygapophyseal)joints Multifidi muscles Ligamentum flavum and interspinous ligaments Erector spinae muscles Sacroiliac j oint
Innervation Sinuvertebral nerves and gray rami corrtrnunicantes Gray rami communicantes Branches from the ventral rami Medial branch nerves Medial branch nerves Branches from the dorsal rami Intermediate and lateral branch nerves Branches from dorsal rami of L5 and sacral nerves
Lumbar Spine Pain from Vertebral Osteophytes
References 1. Bogduk N. The innervation of the lumbar spine. Spine i983: 8: 286-293. 2. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988: 318: 291-300. 3. Deyo RA. Conservative therapy for low back pain: distinguishing useful from useless therapy. JAMA 1983: 250: 1057-1062. 4. Frymoyer JW, Newberg A, Pope MH, Wilder DG,
•
Lamer
351
Clements J, tvlacPherson B. Spine radiographs in patients with low back pain. J Bone Joint Surg 1984: 66A: 1048-1055. 5. Hogan QH, Abram SE. Neural blockade for diagnosis and prognosi,,;: a review. Anesthesiology 1997: 86: 216-241. 6. Dreyfuss P, Michealsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine i996: 21: 2594-2602.
Case Reports Lumbar Spine Pain Originating From
Vertebral Osteophytes Tim J. Lamer, M.D.
Background and Objectives. Axial spine pain originates from a number of structures.
Putative pain generators include facet joints, intervertebral disks, sacroiliac joints, and myofascial structures. Osteophytes originating from lumbar vertebral bodies in the area of the intervertebral disks may be a source of nociceptive low back pain which may respond to local injection. Methods. Five patients with axial low back pain unresponsive to traditional treatment modalities were treated with fluoroscopic guided injection of local anesthetic and corticosteroid near large intervertebral osteophytes. Results. All 5 patients experienced relief. Conclusion. Vertebral osteophytes may be a source of axial spine pain. Injection of painful osteophytes with a local anesthetic and corticosteroid solution may produce pain relief. Reg Anesth Pain Med 1999: 24: 347351.
Key words: back pain, vertebral osteophyte, spine injection.
Methods
Nociceptive axial spine pain m a y originate from several sources including facet joints, intervertebral disks, sacroiliac joints, and myofascial structures (1). Traditional therapies include therapeutic exercise, physical modalities (heat, ice, electrical stimulation), a n t i n f l a m m a t o r y drugs, and local injections. This report describes five patients with extensive degenerative spine arthritis and large vertebral osteophytes w h o obtained relief from fluoroscopic-guided injection of the osteophytes with a local anesthetic-corticosteroid solution after failing to improve from traditional m a n a g e m e n t techniques.
Five patients with axial low back pain were treated with one or m o r e osteophyte injections. Two patients had unilateral osteophytes at one vertebral level, two patients had bilateral osteophytes at one vertebral level, and one patient had unilateral osteophytes at two adjacent vertebral levels. All of the patients presented with nonradicular, axial low back pain, n o r m a l neurologic examination, and lumbar spine radiographs demonstrating extensive degenerative joint disease of the lumbar spine. The patients were treated initially with an e x t e n d e d course of m o r e traditional therapeutic interventions including nonsteroidal antinflammatory drugs (NSAIDs), oral opioids, epidural and facet injections, and therapeutic exercise u n d e r the guidance of a physiatrist. After failing to respond to these interventions, the patients were treated with local osteophyte injection. After the initial injection, all the patients were followed for an e x t e n d e d period of time. If the patient experienced recurrent pain following a period of pain relief, the injection was repeated. The
From the Division ot Pain Medicine, Mayo Clinic Jacksonville, Jacksonville, Florida. Accepted for publication March 19, 1999. Reprint requests: Tim J. Lamer, M.D., Division of Pain Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224. Copyright © 1999 by the American Society of Regional Anesthesia. 0146-521X/99/2404-001255.00/0
347
348
Regional Anesthesia and Pain Medicine Vol. 24 No 4 July-August 1999
interval between injections was determined by the duration of pain relief after each injection. The technique was performed with the patients placed in the prone position on a fluoroscopy table. Preinjection localization of the needle entry site(s) was performed with fluoroscopy. The needle entry site was 6 - 7 cm from the midline in all cases. An oblique approach similar to the technique used to perform lumbar sympathetic block was used. After local anesthesia of the skin and deeper tissues was placed, a 22-gauge, 15-cm needle was advanced using fluoroscopic guidance, until it contacted the hypertrophic osteophyte(s) which were typically located at the anterolateral aspect of the disks in all cases. Lateral, oblique, and posteroanterior (PA) fluoroscopy and injection of 0.5-1.0 mL ot iopamidol contrast was used to confirm needle placement at the tip of the protruding osteophyte and spread of injectant around the area of the osteophyte (Fig. 1, 2A-C). In all cases, 1.0 mL was sufficient to cover the affected area. This was followed by injection of 2-3 mL lidocaine (0.5-1%) plus a corticosteroid suspension (6 mg betamethasone or 40 mg triamcinolone) at each osteophyte.
Case Report A 62-year-old male presented with a history of axial, nonradicular low back pain of several years duration. His pain was worse with bending and twisting activities, was localized to the right lower lumbar paraspinal area, and had an average pain intensity of 8/10. Previous treatments including multiple NSAIDs, electrical stimulation, therapeutic exercise, and epidural and facet injections were not beneficial. Physical examination revealed normal lower extremity strength, sensation, and symmetric deep tendon reflexes. Straight leg raising was negative for radicular pain. There was minimal paraspinal tenderness, and he experienced reproduction of his pain with lateral bending toward the right side. Lumbar spine radiographs revealed extensive degenerative disk and facet disease. Flexion-extension and lateral bending films did not demonstrate excessive movement. Magnetic resonance imaging with and without gadolinium revealed degenerative disks and facets at multiple lumbar levels-most pronounced at L4-LS. There was advanced degenerative disk disease at L4-L5 with a large anterior osteophyte. An initial osteophyte injection at L4-L5 on the right resulted in significant improvement with a post-injection pain score of 4/10. A repeat injection 1 month later resulted in more improvement, with a pain score of 2/10. In addition, the patient was able to resume playing golf. The patient has been seen for 3 years and receives two to three injections per year. He typically experiences 2-3 months of excellent relief followed by a gradual increase in symptoms leading up to the next injection. He has remained very active, continuing to work and play golf.
Results
Fig. 1. Image obtained from fluoroscopic-guided needle placement for osteophyte injection. Arrows identify the radiopaque contrast, which has spread between the L4 and S1 vertebral osteophytes.
All five patients had significant improvement following the injection, with postinjection pain scores decreasing by 50% or more. All patients had recurrent pain and required one or more repeat injections (Table 1). One patient received four injections, each time experiencing pain relief but only for the duration of the local anesthesia. The injections were discontinued because of a lack of a long-term response, and the patient was treated with opioid medications. Two patients had sufficient relief following a series of injections that they did not require repeat injections. Two patients experienced extended relief and continue to be seen periodically for reinjection (two to three times
Lumbar Spine Pain from Vertebral Osteophytes
•
Lamer 349
Fig. 2. (A) Posteroanterior view of needle placement at the tip of an L4-L5 osteophyte. (B) Oblique view of the same needle placement at L4-L5. (C) Spread of contrast injected through same needle seen in Fig. 2B. The contrast has spread around the protruding tip of the osteophyte. The small arrows outline the L5-S1 facet joint.
per year). No complications attributed to the procedure were identified.
Discussion Nociceptive spine pain m a y originate f r o m several musculoskeletal structures (Table 2). Traditional therapeutic interventions for musculoskeletal low back pain typically consist of one or m o r e of the following: oral medications, physical modalit~es, and t h e r a p e u t i c exercise (2,3). A l t h o u g h the role of
facet, myofascial trigger point, sacroiliac, intradiscal, and epidural injections are controversial, properly selected patients m a y benefit f r o m such treatment. The c o n c e p t of v e r t e b r a l o s t e o p h y t e s as a source of n o c i c e p t i v e p a i n a n d t r e a t m e n t w i t h injection t h e r a p y is n o t well described. F r y m o y e r et al. d e m o n s t r a t e d a c o r r e l a t i o n b e t w e e n the p r e s e n c e of l u m b a r v e r t e b r a l o s t e o p h y t e s a n d sev e r e l o w b a c k p a i n a n d l o w e r e x t r e m i t y p a i n (4). It is u n c l e a r w h y s o m e p a t i e n t s d e v e l o p t h e s e o s t e o p h y t e s , a n d in t h o s e t h a t h a v e t h e m , it is
350
Regional Anesthesia and Pain Medicine Vol. 24 No. 4 July-August 1999 Table 1. Results of Osteophyte Injection
Preinjection Pain Score
Patient
Site
67 male 76 male
Right L4-L5 Right L3-L4 Left L4-L5 Right L4-L5 Bilateral L4-L5 Bilateral L4-L5
62 male 71 male 68 male
Postinjection Pain Score
Total Follow-up Period (months)
Total No. Injections
Outcome
8/10
2/10
24
3
A*
8/10 8/10 5-8/10 8/10
3/10 4/10 0 4/10
12 36 12 3
6 6 2 4
By By A* C*
* Resolution of pain. t Extended pain relief: periodic reinjection required. ~ Relief for duration of local anesthetic only.
u n c l e a r w h y some cause pain a n d some do not. The p a t h o p h y s i o l o g i c events leading to the form a t i o n of these large o s t e o p h y t e s is n o t k n o w n . The relief of pain following injection w i t h local anesthetic, t h o u g h n o t absolutely diagnostic, is o n e piece of evidence that vertebral o s t e o p h y t e s m a y be a source of pain. The limitations of diagnostic a n d t h e r a p e u t i c inferences m a d e by observing the response to local anesthetic blocks are well r e c o g n i z e d (5). Pain relief following local blocks m a y result f r o m the t h e r a p e u t i c effect of the block, a systemic effect of the injectant(s), spread of the injectant to adjacent structures (e.g., n e r v e root, s y m p a t h e t i c trunk, or gray rami c o m m u n i c a n s ) , or a placebo response. Despite these limitations, carefully controlled fluoroscopic guided injections c u r r e n t l y are the best diagnostic test to d e t e r m i n e the source of pain in patients w i t h axial spine pain as it has b e e n d e m o n s t r a t e d that h i s t o r y a n d physical e x a m i n a tion are unreliable in localizing the source of pain (6). All five of the patients described in this series h a d extensive p r e v i o u s t r e a t m e n t including epidural steroid injections, w i t h o u t i m p r o v e m e n t , w h i c h suggests but does n o t p r o v e that placebo response, adjacent spread, a n d systemic effects w e r e n o t o p e r a n t in the patients described here. In all five cases, the injection was p e r f o r m e d w i t h
the needle placed at the m o s t p r o t u b e r a n t tip of the o s t e o p h y t e , d e t e r m i n e d f r o m PA, lateral, a n d oblique fluoroscopic images. A small a m o u n t of contrast dye c o n f i r m e d spread of the injection a r o u n d the area of the o s t e o p h y t e a n d lack of spread far b e y o n d the target. In n o case was t h e r e spread to the intervertebral f o r a m e n , facet joint, or epidural space. These injections are performed to deposit the injectant a r o u n d the tip of the protruding osteophyte. On occasion, some injectant will spread b e t w e e n the osteophytic c o m p o n e n t s from the two vertebrae involved (Fig. 1). This is not related in a n y w a y to provocative discography in w h i c h a needle is placed into the center of the disk and contrast or other material is injected.
Conclusion A variety of structures m a y c o n t r i b u t e to nociceptive low back pain. Patients w i t h back pain a n d the presence of large l u m b a r spine osteop h y t e s w h o do n o t r e s p o n d to traditional t h e r a peutic m e a s u r e s m a y be candidates for injection of the o s t e o p h y t e ( s ) w i t h a local a n e s t h e t i c - c o r ticosteroid solution.
Table 2. Putative Sources of Musculoskeletal Low Back Pain
Structure Structures innervated by branches from ventral rami Intervertebral disk Anterior and posterior longitudinal ligaments Psoas and quadratus lumborum muscles Structures innervated by branches from dorsal rami Facet (zygapophyseal)joints Multifidi muscles Ligamentum flavum and interspinous ligaments Erector spinae muscles Sacroiliac j oint
Innervation Sinuvertebral nerves and gray rami corrtrnunicantes Gray rami communicantes Branches from the ventral rami Medial branch nerves Medial branch nerves Branches from the dorsal rami Intermediate and lateral branch nerves Branches from dorsal rami of L5 and sacral nerves
Lumbar Spine Pain from Vertebral Osteophytes
References 1. Bogduk N. The innervation of the lumbar spine. Spine i983: 8: 286-293. 2. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988: 318: 291-300. 3. Deyo RA. Conservative therapy for low back pain: distinguishing useful from useless therapy. JAMA 1983: 250: 1057-1062. 4. Frymoyer JW, Newberg A, Pope MH, Wilder DG,
•
Lamer
351
Clements J, tvlacPherson B. Spine radiographs in patients with low back pain. J Bone Joint Surg 1984: 66A: 1048-1055. 5. Hogan QH, Abram SE. Neural blockade for diagnosis and prognosi,,;: a review. Anesthesiology 1997: 86: 216-241. 6. Dreyfuss P, Michealsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine i996: 21: 2594-2602.