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Int J Spine Surg. 2018 Aug 15;12(3):388-392. doi: 10.14444/5045. eCollection 2018 Jun.

Treatment of Low Back Pain by Treating the Annular High Intensity Zone (HIZ) Lesions Using Percutaneous Transforaminal Endoscopic Disc Surgery.

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Department of Orthopaedics and Spine Surgery, Kovai Medical Center and Hospitals, Coimbatore, Tamilnadu, India.
Endoscopic Spine Surgeon, Pune, India.



The study design was a retrospective case series. The objective was to find the clinical success rate of percutaneous transforaminal endoscopic disc surgery in patients suffering from discogenic chronic low back pain who were showing high intensity zone (HIZ) with degenerated disc as the only abnormality in the magnetic resonance imaging (MRI). The HIZ in the posterior annulus in degenerated disc is recognized as a pain generator. There are only a few studies available in the literature addressing the effect of identification and treatment of HIZ in the chronic low back pain patient.


We retrospectively evaluated the case records of all the patients who were treated by percutaneous endoscopic disc surgery for relief of symptoms as determined by visual analog scale (VAS) score, Oswestry Disability Index (ODI), Mac Nab criteria, and the consumption of analgesics, who had the predominant symptom of chronic low back pain, and whose lumbar spine MRI showed degenerated disc with HIZ and no other cause of back pain, like facet joint arthritis or sacroiliac joint arthritis.


A total of 23 patients were identified to include in the study. Mean preoperative duration of low back pain was 13.1 months. Mean follow up after the procedure was 29 months. At final follow up, 69.6% of the patients were not taking any pain medicines, 17.36% were on frequent analgesic medicines, 13.04% were on occasional analgesics. There was statistically significant reduction in VAS at 6 weeks postop and final follow up after surgery and the ODI at final follow up; 82.6% of patients had an excellent/good outcome as per Mac Nab criteria. There were no complications or reoperations in any of the patients.


Visualization and ablation of the chronic annular pathology in HIZ may give an effective and minimally invasive treatment for one of the back pain causes.


annular tear; chronic low back pain; endoscopic ablation; high intensity zone

Conflict of interest statement

Disclosures and COI: The authors declare that there is no conflict of interest regarding the publication or content of this paper.

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