Percutaneous nucleoplasty for discoradicular conflict.

Transcription

1 Percutaneous nucleoplasty for discoradicular conflict. Poster No.: C-0599 Congress: ECR 2011 Type: Scientific Exhibit Authors: A. Alexandre, G. G. Giardina, L. Coro', A. Alexandre ; Rome/ IT, Treviso/IT Keywords: Puncture, MR, Fluoroscopy, CT, Spine, Neuroradiology spine, Interventional non-vascular DOI: /ecr2011/C-0599 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose Nucleoplasty is a simple and safe minimally invasive procedure developed to treat patients with contained herniated discs by a controlled ablation of the nucleus pulposus. It has been firstly introduced in 1999, after receiving U.S. Food and Drug Administration (FDA) approval. The aim of our investigation was to evaluate clinical results of nucleoplasty on contained lumbar disc herniations, with an overall follow-up of 4 years. Methods and Materials Procedure The procedure can be perfomed both in an operating theatre or in an angiographic one. This procedure is performed under local anesthesia, but most of the patients also receive intravenous sedation and analgesia, to help them relax and make the procedure easier to tolerate. The amount of sedation given depends upon the patient, but generally is a mild sedation. The patient is monitored with an electrocardiogram, blood pressure cuff and blood oxygen-monitoring device. Page 2 of 17

3 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY Page 3 of 17

4 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY Nucleoplasty does not involve an incision. You can identify the level you want to treat under fluoroscopy; then identify the posterior spinous line and move 5 to 10 cm laterally, and enter the skin with the needle with an angle of approximately 45 degree to reach the disc. Page 4 of 17

5 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY Page 5 of 17

6 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY By posterolateral approach under fluoroscopy through a 17G needle the SpineWand electrode is introduced and radiofrequency is applied, to provoke ablation of the nucleus pulposus. The correct position of the cannula entering the annulus must be verified in both laterolateral and antero-posterior views. Page 6 of 17

7 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY Page 7 of 17

8 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY Identification of Kambin's triangle is mandatory, also known as the "safe triangular working zone", the base is the superior endplate of the inferior vertebra, the height is the lateral border of the tecal sac, and the hipotenuse is the spinal nerve. Page 8 of 17

9 References: Modified - Page 9 of 17

10 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY The first step of nucleoplasty procedure is Ablation: advancing the Wand creates a small channel in the nucleus. Page 10 of 17

11 References: Modified - Pain Physician, Volume 5, Number 2, pp The second step is Bipolar Radio Frequency: coagulation during withdrawal of the Wand denatures the adjacent collagen and proteoglycan within the nucleus, determinating and additional volume and pressure reduction, without termal or structural damage to the adjacent tissues. Page 11 of 17

12 References: Modified - Pain Physician, Volume 5, Number 2, pp At least 6 channels are made, as this corresponds approximately to 1 cc of tissue volume. Page 12 of 17

13 References: Modified - Pain Physician, Volume 5, Number 2, pp Nucleoplasty takes about 30 to 40 minutes. Typically driving, lifting, bending/twisting are generally restricted in the first 2 weeks. Formal physical therapy may begin at 1 week post-procedure. Patients Our group is composed by 1390 patients with contained lumbar disc herniation (consecutive series from 2003 to 2006), that can be divided by the level in: in L3-L4-989 in L4-L5-167 in L5-S1 According to the litterature selection criterias for nucleoplasty were: Page 13 of 17

14 Morphological Indications: MRI evidence of contained lumbar disc herniation with intact anulus Clinical Indications: leg pain with or without back pain and failure of 6 weeks of conservative therapy Contraindications were: Severe degenerative disc disease (greater than 33% loss of disc height) Disc extrusion or sequestration Results We evaluated clinical improvement using Roland Morris questionnaire, and we considered a Roland Morris improvement of =/> 70 % an excellent result, 50 to 70 % improvement a good result, 20 to 50% improvement an insufficient result, and <20% improvement as no result. Results can be resumed in the table: Results 12 months 24 months 36 months 48 months 1319 pat. 678 pat. 201 pat. 80 pat. Excellent 70% score improvement % 49.2 % 46.2% 42.5 % Good 50-70% score improvement % 28.9 % % 27.5 % Insufficient >50% % 12.9 % no result >20% score improvement 8.49 % 8.9 % % 30 % score improvement Page 14 of 17

15 References: A. Alexandre; Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Rome, ITALY MRI or CT have been performed 6 months after the procedure, in 498 cases. Bulging was: eliminated in 128 significantly reduced in 222 unvaried in 148 This case distribution anyway is not directly correlated to the quality of the clinical outcome. Coblation just perforates the anulus, without disruption of surrounding structures, it provoques a small volume loss entailing a large fall of pressure. The observed initial decreases in interleukine 1, which has hyperalgesic effects, followed by augmentation in interleukine 8, which may express the reparatory response, might correspond to the twostep clinical amelioration, initially due to the rapid discal loss of volume, and later due to the progressive discal repair. Byochemical modification may correspond to the clinical result more than morphological ones. Page 15 of 17

16 Conclusion Nucleoplasty is a safe procedure. There have been no infections, bleeding, nerve root injuries or worsening of symptoms after the procedure. The most common side effect is discomfort, which is temporary. Byochemical modifications may correspond to the clinical result more that morphological ones. Anyway by this minimally invasive procedure patients will not be out of physiotherapy, and out of normal activities for more than a few days. References Sharps LS, Isaac Z. Percutaneous Disc Decompression Using Nuceoplasty. Pain Physician. Volume 5, 2: Welch WC, Gerszten PC. Alternative strategies for lumbar discectomy: intradiscal electrothermy and nucleoplasty. Neurosurg Focus 13: Chen YC, Lee S, Saenz Y, Lehman NL. Histologic findings of disc, end plate and neural elements after coblation of nucleus pulposus: an experimental nucleoplasty study. Spine Journal 3: Chen YC, Lee S, Chen D. Indradiscal pressure study of percutaneous disc decompression with nucleoplasty in human cadavers. Spine 28, 7: O'Neill CW, Liu JJ, Leibenberg E, Hu SS, Deviren V, Tay BK, Chin CT, Lotz JC. Percutaneous plasma decompression alters cytokine expression in injured porcine intervertebral discs. Spine J. 4(1): Personal Information Page 16 of 17

17 Alexandre A., Giardina G.G. : Department of Bioimaging and Radiological Sciences - Institute of Radiology - Catholic University of Sacred Heart. Rome. Italy. andrea.alexandre@libero.it Alexandre A., Corò L. European Neurosurgical Institute (EU.N.I.) - Dvision of Neurosurgery. Treviso. Italy. info@eunionline.com Page 17 of 17