OBJECTIVES: Almost every individual will suffer an episode of low back pain (LBP) that disrupts normal activities; however, 5% of patients will experience severe pain and functional impairment chronically. This group consumes approximately 90% of health care costs for LBP, and the prognosis for recovery with non-surgical management alone is poor. Current surgical preference is spinal fusion (SF), which is being utilized with escalating frequency. Intradiscal electrothermal therapy (IDET) is a minimally invasive, less costly alternative to SF. This systematic review compared clinical outcomes in patients undergoing IDET or SF for discogenic LBP. METHODS: English-language articles published from January 1995 through December 2006 were identified through searching the PubMed database and bibliographies. Articles were selected if disc degeneration or disruption was the primary indication, and if follow-up outcome data included evaluations of back pain severity, functional impairment and/or quality of life. Data were extracted and summarized on patient characteristics, surgical methods and clinical outcomes. RESULTS: The search yielded 231 articles; 53 met stated criteria (20 IDET, 33 SF). Overall, there were similar median percentage improvements realized after IDET or SF, respectively, for 2 of the 3 outcomes evaluated: pain severity (52%, 50%), back function (14%, 42%) and quality of life (43%, 46%). Perioperative complications were common with SF (median: 14%) whereas adverse events were rare with IDET (median: 0%). The median percentage of IDET patients experiencing a minimal clinically important improvement in pain severity was 61%. CONCLUSION: Patients with intractable discogenic LBP have a poor prognosis for recovery with few treatment options. IDET offers a minimally-invasive intermediate step in their continuum of care, with symptom amelioration comparable to SF without the surgical invasiveness, attendant complications and high costs. It may be prudent to offer IDET prior to SF in carefully-selected patients with definitive evidence of internal disc disruption.