***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Study Design . Single blind r and omized study . Objectives . To compare the effectiveness of  lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration . Summary of Background Data . To the authors ’ best knowledge , only one r and omized study has evaluated the effectiveness of lumbar fusion . The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician . Patients and Methods . Sixty-four patients aged 25–60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4–L5 and /or L5–S1 at radiographic examination were r and omized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy , or cognitive intervention and exercises . The cognitive intervention consisted of a lecture to give the patient an underst and ing that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it . This was reinforced by three daily physical exercise sessions for 3 weeks . The main outcome measure was the Oswestry Disability Index . Results . At the 1-year follow-up visit , 97 % of the patients , including 6 patients who had either not attended treatment or changed groups , were examined . The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery , compared with 42 to 30 after cognitive intervention and exercises . The mean difference between groups was 2.3 ( −6.7 to 11.4 ) ( P = 0.33 ) . Improvements inback pain , use of analgesics , emotional distress , life satisfaction , and return to work were not different . Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment , and lower limb pain was reduced more after surgery . The success rateaccording to an independent observer was 70 % after surgery and 76 % after cognitive intervention and exercises .  The early complication rate in the surgical group was 18 % . Conclusion . The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration r and omized to cognitive intervention and exercises , or lumbar fusion BACKGROUND CONTEXT The clinical entity " discogenic back pain " remains controversial at fundamental levels , including its pathophysiology , diagnostic criteria , and optimal treatment . This is true despite availability of four r and omized trials comparing the efficacy of surgical and nonsurgical treatments . One trial showed benefit for lumbar fusion compared with unstructured nonoperative care , and three others showed roughly similar results for lumbar surgery and structured rehabilitation . PURPOSE To compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels . DESIGN Prospect i ve observational cohort study . PATIENT SAMPLE Patients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area . OUTCOME MEASURES Rol and -Morris back disability score ( primary outcome ) , current rating of overall pain severity on a numerical scale , back and leg pain bothersomeness measures , the physical function scale of the short-form 36 version 2 question naire , use of medications for pain , work status , emergency department visits , hospitalizations , and further surgery . METHODS Patients receiving spine surgery within 6 months of enrollment were design ated as the " surgical treatment " group and the remainder as " nonsurgical treatment . " Outcomes were assessed at 3 , 6 , 9 , and 12 months after enrollment . RESULTS We enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons . Eighty-six patients ( 17 % ) had surgery within 6 months of enrollment . Surgery consisted of instrumented fusion ( 79 % ) , disc replacement ( 12 % ) , laminectomy , or discectomy ( 9 % ) . Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery . Adjusting for baseline differences among groups , surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified ( 23-point ) Rol and disability question naire ( primary outcome ) 1 year after enrollment . Using a composite definition of success incorporating 30 % improvement in the Rol and score , 30 % improvement in pain , no opioid pain medication use , and working ( if relevant ) , the 1-year success rate was 33 % for surgery and 15 % for nonsurgical treatment . The rate of reoperation was 11 % in the surgical group ; the rate of surgery after treatment design ation in the nonsurgical group was 6 % at 12 months after enrollment . CONCLUSIONS The surgical group showed greater improvement at 1 year compared with the nonsurgical group , although the composite success rate for both treatment groups was only fair . The results should be interpreted cautiously because outcomes are short term , and treatment was not r and omly assigned . Only 5 % of nonsurgical patients received  cognitive behavior therapy .  Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines OBJECTIVE There is no consensus on the treatment of chronic low back pain of disc origin in the medical literature . The few prospect i ve , r and omized , controlled studies evaluating the effectiveness of caudal epidural steroid injections ( CESI ) have obtained contradictory results . The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability . MATERIAL AND METHOD This is a prospect i ve , r and omized , case-control study of a group of 46 patients with chronic low back disc pain . Patients were r and omly allocated into 2 groups to either receive fluoroscopy guided CESI ( CESI-group ) , or oral non-steroidal anti-inflammatory drugs ( NSAID-group ) . All patients were clinical ly evaluated at 4 , 12 , and 24 weeks , and according to the indications of the Spanish Society for Study of Diseases of the Spine ( GEER ) . RESULTS Lumbar pain , measured by the visual analog scale ( VAS ) and the Oswestry Low Back Pain Disability Question naire ( ODQ ) , did not improve significantly during follow-up in any of the two study groups ( P>.05 ) . Younger patients , women , patients with shorter duration of symptoms , low physical job dem and , without leg pain , and sport-active , included in CESI-group showed a trend towards better results , but none reached statistical significance ( P>.05 ) . CONCLUSIONS The present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disc origin . While CESI could show some improvement in patients with degenerative lumbar disc disease , we consider it should be used with caution , informing patients about realistic expectations on the success of treatment Background Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology . The purpose of this study was to evaluate the epidurographic findings for the midline , transforaminal and parasagittal approaches in lumbar epidural steroid injections , and correlating them with the clinical improvement . Methods Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled . After screening the patients according to the exclusion criteria and r and omly allocating them to 3 groups of 20 patients , fluoroscopic contrast enhanced epidural steroids were injected via midline ( group 1 ) , transforaminal ( group 2 ) and parasagittal interlaminar ( group 3 ) approaches at the level of the pathology . The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months ; any incidences of complications were recorded . Results The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups ( P < 0.05 ) . The epidurography showed a better ventral spread for both the transforaminal ( P < 0.001 ) and the paramedian approaches ( P < 0.05 ) , as compared to the midline approach . The nerve root filling was greater in the transforaminal group ( P < 0.001 ) than in the other two groups . The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 ( P < 0.05 ) , and highly significant in groups 2 and 3 ( P < 0.001 ) . In all the groups , any complications observed were transient and minor . Conclusions The midline and paramedian approaches are technically easier and statistically comparable , but clinical ly less efficacious than the transforaminal approach . The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement . However , an longer follow-up period is advisable for a better evaluation of the actual outcom Among the multiple causes of chronic low back pain , axial and discogenic pain are common . Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections . However , there is a paucity of evidence regarding the effectiveness , indications , and medical necessity of any treatment modality utilized for managing axial or discogenic pain , including epidural injections . In an interventional pain management practice in the US , a r and omized , double-blind , active control trial was conducted . The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin . However , disc herniation , radiculitis , facet joint pain , or sacroiliac joint pain were excluded . Two groups of patients were studied , with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone . Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the , Oswestry Disability Index , Secondary outcome measurements included employment status , and opioid intake . Significant improvement or success was defined as at least a 50 % decrease in pain and disability . Significant improvement was seen in 77 % of the patients in Group I and 67 % of the patients in Group II . In the successful groups ( those with at least 3 weeks of relief with the first two procedures ) , the improvement was 84 % in Group I and 71 % in Group II . For those with chronic function-limiting low back pain refractory to conservative management , it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain . This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source Abstract Objectives To assess the clinical effectiveness of surgical stabilisation ( spinal fusion ) compared with intensive rehabilitation for patients with chronic low back pain . Design Multicentre r and omised controlled trial . Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom . Participants 349 participants aged 18 - 55 with chronic low back pain of at least one year 's duration who were considered c and i date s for spinal fusion . Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy . Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after r and omisation . The SF-36 instrument was used as a secondary outcome measure . Results 176 participants were assigned to surgery and 173 to rehabilitation . 284 ( 81 % ) provided follow-up data at 24 months . The mean Oswestry disability index changed favourably from 46.5 ( SD 14.6 ) to 34.0 ( SD 21.1 ) in the surgery group and from 44.8 ( SD14.8 ) to 36.1 ( SD 20.6 ) in the rehabilitation group . The estimated mean difference between the groups was –4.1 ( 95 % confidence interval –8.1 to –0.1 , P = 0.045 ) in favour of surgery . No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures . Conclusions Both groups reported reductions in disability during two years of follow-up , possibly unrelated to the interventions . The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference , and the potential risk and additional cost of surgery also need to be considered . No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation Study Design : Comparative assessment of r and omized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain . Objective : To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain . Summary of Background Data : Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain , which is pain exclusive of that associated with a herniated intervertebral disc , or that is due to degeneration of the zygapophyseal joints , or due to dysfunction of the sacroiliac joints , respectively . The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited . Methods : The present analysis is based on 2 r and omized controlled trials of chronic axial low back pain not caused by disc herniation , radiculitis , or facet joint pain , utilizing either a caudal or lumbar interlaminar approach , with a total of 240 patients studied , and a 24-month follow-up . Patients were assigned to receive 
    Output:
    
The level of evidence was based on the grading of evidence criteria which , was conducted using 5 levels of evidence ranging from levels I to V. RESULTS Based on a qualitative assessment of the evidence for both approaches , there is Level II evidence for epidural injections , either caudal or lumbar interlaminar .
The available evidence suggests fluoroscopically directed epidural injections provide long-term improvement in back and lower extremity pain for patients with lumbar discogenic pain .
There is also limited evidence showing the potential effectiveness of surgical interventions compared to nonsurgical treatments