Treatment of Common Low Back Pain: A New Approach to an Old Problem.

Low back pain is very common, but the pathophysiology is poorly understood. We present a new hypothesis regarding the pathophysiology of common low back pain supported by our flexible endoscopic observations of the epidural cavity (epiduroscopy), anatomic dissection of embalmed and fresh cadavers, and careful review of preexisting information available on the anatomy of the epidural space and neuroforamen. A new approach to the treatment of common low back pain based on the hypothesis was developed and is presented in the case reports of five patients. Treatment focuses on a perichondrium derivative; the peridural membrane, which creates a suprapedicular compartment in the neuroforamen where we hypothesize inflammatory material accumulates. This produces common low back pain by causing inflammation and sensitization of the peridural membrane and periosteum that forms the boundaries of this compartment. Percutaneous Ablation and Curettage and Inferior Foraminotomy (PACIF(sm)) aims to destroy the peridural membrane, denervate sensitive structures, and remove inflammatory tissues from the suprapedicular canal. The proposed mechanism of action and safety of PACIF(sm) is discussed in the context of epidural and neuroforaminal anatomy. As shown by the five case reports, PACIF(sm) appears to be highly effective and safe, warranting further evaluation.