Basic Intradiscal techniques. Amar salti.md,edra Consultant Anesthesia and Pain Medicine SKMC - Abu Dhabi - UAE

Transcription

1 Basic Intradiscal techniques Amar salti.md,edra Consultant Anesthesia and Pain Medicine SKMC - Abu Dhabi - UAE

2 Learning Objectives Indications for IntraDiscal tech. Discogenic Back Pain Diagnostic Discography Intradiscal Intervetions Radicular Pain Percutaneous Disc Decompression

3 Low Back Pain

4 Back Pain At some time in life, 70 to 85% of all people have back pain, annual prevalence: 15-45% The primary site of back pain is the lower back in 85% of back pain sufferers #1 reason of activity limitation in people below 45 years of age #2 reason for doctor visits and absenteeism from work #3 reason for surgical interventions ( ) Huge economic implications NIH guide. Research on low back pain and spinal disorders

5 Discogenic leg pain is a primary cause of health care expenditure in the U.S.A., afflicting nearly 10 million people at an estimated cost of over $20 billion. 1. Lipetz JS. Pathophysiology of inflammatory, degenerative,and compressive radiculopathies. Phys Med Rehabil Clin N Am. 2002;13: Carey TS, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. N Engl J Med. 1995;333:

6 Back Pain-Etiology Back Pain ~ Waste Basket Diagnosis

7 Axial Low Back Pain In the absence of Failed back surgery syndrome: Two main causes Discogenic Low Back Pain Facet Syndrome

8 Discogenic Low Back Pain Discogenic pain results from internal disc disruption (IDD) Responsible for chronic low back pain in ~ 40% of cases Annular fissures and delamination of the annulus are possible causes of chronic discogenic pain Schwartzer AC, Aprill CN, Derby R et al. Spine 20: , 1995

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10 Pain Distribution Discogenic Sciatica

11 Chronic Discogenic Low Back Pain (CDLBP) Typically occurs in younger patients Pain worse with Sitting (sitting intolerance < min) Spine flexion MRI lumbar spine: degeneration (black discs on T2 view) without significant disc herniation or spinal stenosis Diagnostic provocative discography: to confirm diagnosis--controversial Treatment: Fusion or IDET; new disc replacement surgery

12 Physical examination No neurologic findings in the lower limbs, negative SLR A positive spring-test -reproduction of axial back pain with direct pressure over the suspect spinous process

13 Fluoroscopic Techniques

14 Discography & Intradiscal Therapy Approach (lateral to Superior Articular Process) Facet joint injection site Medial branch block injection site Epidural access Pars Selective nerve root block Lamina Scottie Dog

15 Kambin s triangle

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17 Needle entry too shallow

18 Needle entry too far lateral

19 Diagnostic discography: Indications To identify symptomatic disc level Recurrent disc vs. scar tissue pain Preliminary test to spinal fusion Preliminary test for IDET, chemonucleolysis, nucleoplasty Negative MRI, symptomatic patient

20 Annular Rupture Endplate Fracture

21 Rational: All are a Disc Volume Reducing Procedure 1) Chemonucleolysis A. Chymopapain B. Methylene Blue C. Oxygen-Ozone D. Gelified Ethanol 2) Annuloplasty A. Intradiscal electrothermal therapy (IDET) B. TDD C. Biacuplasty 3) Nucleoplasty and Nucleotomy A. APLD-automated percutaneous lumbar discectomy B. Laser Discectomy C. Radiofrequency Coblation (plasma discectomy) D. Mechanical Disc Decompression (dekompressor)

22 Reported complication rates by discectomy technique Complication rate (%) Complications Open Microscopic Endoscopic Microendoscopic 0.2 Percutaneous Diskitis Vascular damage Neurological damage x x x x x x x x x x x x x (1) Stolke D, et al. Intraoperative and postoperative complications associated with lumbar spine surgery, Spine (1989) (2) Kambin P. Arthroscopic microdiscctomy, in Mayer HM (ed): Minimally Invasive Spine Surgery: A Surgical Manual (2000) (3) Foley KT, et al. Microendoscopic discectomy, Tech Neurosurgery (1997) (4) Teng GJ, et al. Automated percutaneous lumbar discectomy: A prospective multi-institutional study, J Vasc Interv Radiol (1997) Note: Percutaneous discectomy complication rate based on APLD technique

23 IDET: IntraDiscal Electrothermal Annuloplasty IDET is a minimally invasive treatment for painful IDD Published studies showed some benefit of this technique in select patients However, ~20-50% of patients did not show any improvement Karasek M, Bogduk N. Spine 25: , 2000 Saal JA, Saal JS. Spine 25: , 2000

24 IDET Mechanism HEAT Collagen remodeling by heat causes collagen to shrink, leading to contraction and thickening of the annulus Sealing of the fissures Destruction of annular nociceptors Saal JA, Saal JS. Spine 25: , 2000

25 IDET Ideal Selection Criteria Common Inclusion Criteria Chronic low back pain unresponsive to nonoperative care > 6 months No evidence of radiculopathy Pain reproduction and/or radial fissure present on discography No prior lumbar spine surgery No evidence of nucleus pulposus herniation on MRI Additional criteria Disc height at least 50% No psychological issues No litigation pending Single level (or two level) degenerative disc disease Absence of lumbar canal stenosis No obesity Non-smoker Freeman BJ et al., Spine Nov 1;30(21):

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28 Complications

29 Evolution of Thermal Intradiscal Therapy Intradiscal RF Sluijter, 1994 IDET Smith and Nephew, 1998 disctrode Tyco / Radionics, 2000 Biacuplasty Baylis Medical, 2006

30 TransDiscal Bipolar RF Disc Treatment Radiofrequency current is concentrated between electrodes on two straight probes. The electrodes are internally cooled allowing deep, even heating and eliminating tissue adherence. Tip Temperature Peripheral Temperature Temperature sensors allow monitoring at the electrode tips and disc periphery. cooled Heating parameters can be adjusted to achieve a specific thermal dose.

31 Pilot Study Results The Visual Analogue Scale (VAS) The Oswestry Disability Index (ODI) calculates the extent of functional disability due to back pain. It is determined based on 10 questions about how patients back pain is affecting their ability to perform daily life activities. Legend Example A reduction in VAS, ODI scores and Opiod use indicate an improvement in patient outcomes. Kapural L et al. Pain Medicine 2008; 9:

32 Randomized Placebo-controlled trial of transdiscal Radiofrequency, Biacuplasty for discogenic low back pain 1894 pts screened,64 enrolled Clinical benefits are the result of non placebo effect Kapural L et al, Pain Medicine 2012 Dec 28

33 Radicular Pain Neuropathic component Etiology Disc Herniation Spinal Stenosis Piriformis Syndrome

34 Disc Herniation Sciatica Notion: disc herniation low back pain and sciatica was popularized of Mixter and Barr in HOWEVER Some patients with large disc herniations have no radicular pain Others have radicular symptoms in the absence of disc herniation Mixter WJ, Barr JS. New Engl J Med 1934; 211: Goupille P et al. Semin.Arthritis Rheum. 1998; 28:

35 Causes of Radiculopathy Compression of nerve roots by mechanical pressure motor deficits but no pain Chemical irritation of nerve roots by herniated discs as a result of leakage of PLA 2 from the nucleus pulposus perineural inflammation and nociceptive sensitization Cavanaugh JM. Spine 1995; 20: Saal JS et al. Spine 1990; 15:

36 Disc Herniation Low back pain associated with radicular symptoms 75-80%-respond to conservative treatment success rate for surgical discectomy is 75-80% For central disc protrusions 41-68%

37 Symptomatic Disc Herniation Treatment Options Rest, medications, physical therapy Epidural Steroid injections (ESI) Percutaneous Disc Decompression (small contained disc protrusions) Microdiscectomy (large disc protrusions or extrusions) Most Patients do not need surgery

38 The term "tear" is used to refer to a localized radial, concentric, or horizontal disruption of the annulus without associated displacement of disc material beyond the limits of the intervertebral disc space. Fardon D.F. et al., Nomenclature and classification of lumbar disc pathology.spine Mar 1;26(5):E93-E113.

39 When a relatively large amount of disc material is displaced, distinction between protrusion (A) and extrusion (B or C) will generally only be possible on sagittal MR sections or sagittal CT reconstructions. Fardon D.F. et al., Nomenclature and classification of lumbar disc pathology.spine Mar 1;26(5):E93-E113.

40 Degenerated disc pain without any prolapse and nerve root irritation Contained disc prolapse pain with root irritation Non-contained disc prolapse pain (extruded and sequestrated disc pain)

41 Interventional Approaches for Disc Protrusions ( 6mm) If epidural injections are not helpful Percutaneous Disc Decompression Coblation (RF)/Nucleoplasty Technique Dekompressor Nucleotomy Heat Based Decompression Automated Percutaneous Lumbar Discectomy Ozone Discolysis Percutaneous Laser Discectomy (LASE)

42 Mechanism hypothesis 1. Mechanical debulking with reduction of pressure on the proximal nerve root. 2. Removing a focal area of disc pathology associated with annular degeneration and ongoing inflammation 3. Activating cellular repair induced by diminished disc wall tension.

43 Automated Percutaneous Lumbar Discectomy-APLD

44 APLD-automated percutaneous Invented by a radiologist Tens of thousands of uses over past 15 years Mechanism: Direct Suction aspiration of nucleus material. Blunt End for Safety lumbar discectomy Studies: inconsistent outcome results J Vasc Interv Radiol >1500 patients, prospective study Success rate: 83% one year Neuroradiology patients, retrospective Satisfaction: 58% at 2 mths, 68% at 6 mths

45 Coblation (RF)/Nucleoplasty

46 Percent Percutaneous Disc Decompression Prospective case study 67 patients 12 months follow up 80% of pts with significant improvement in VAS No complications Using Coblation Percentage of Patients reporting improvement in Numeric pain post Nucleoplasty Follow Up Period (months) V Singh MD, et al, Pain Physician, 2002

47 Percutaneous Nucleotomy DeKompressor

48 Percutaneous discectomy:dekompressor : significant improvement in functionality, pain scores (VAS) of 60.25% (P < 0.001), and patient satisfaction in carefully selected patients with radicular pain. Less annular disruption and small disc volume extractions should limit future disc degeneration and improve long-term efficacy Kenneth M. Alò et al, Pain Practice, Volume 4, Issue 1,

49 Percutaneous Disc Nucleotomy

50 Percutaneous Discectomy The Procedure 1 cc nucleus extracted disc decompressed and leg pain reduced. Procedure takes less than 30 minutes.

51 Laser Discectomy

52 Medical lasers have been used since the early 1960s Mechanism of action: Laser light is converted to heat in the tissue. At 100 C, tissue vaporizes and ablation takes places Vaporization of nucleus pulposus cause volume reduction and decreases intradiscal pressure, allowing the disc to return to its normal state

53 Percutaneous LASER Lumbar decompression

54 ASIPP Guidelines

55 Evidence Levels APLD: Level II-2 Nucleoplasty: Level II-3 Dekompressor: Level III Laser Decompression: Level II-2 IDET: Level II-2 Biacuplasty: Level III Hirsch JA et al., Pain Physician May-Jun;12(3): Manchikanti L et al., Pain Physician May-Jun;12(3): Singh V et al., Pain Physician May-Jun;12(3): Singh V et al., Pain Physician May-Jun;12(3): Helm S et al., Pain Physician Jan-Feb;12(1):207-32

56 Both Nucleoplasty and Disc Dekompressor are effective therapies. Regardless of the different mechanism no significant differences in the outcomes were found. Both techniques result in significant reductions in levels of disability and incapacity for work as well as decreased analgesic consumption Lemcke J et l., Minim Invasive Neurosurg Oct;53(5-6):

57 Sung Eun Sim, et al. Korean J Pain March;24(1):36-43.

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60 Intradiscal Ozone Injection 72

61 Intradiscal Ozone

62 The AO-1000 Device

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64 Joimax

65 Disc FX

66 Eur Spine J Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial Alessandro Cesaroni and Pier Vittorio Nardi PDD improved pain relief as well as superior immediate and longterm gains in functional ability and quality of life when compared to conservative therapies. PDD is a minimally invasive treatment option for symptomatic contained disc herniation that provides an excellent medium for both results and safety.

67 Plasma D30 system PDCT (Percutaneous Disc Coagulation Therapy) Creates plasma light and irradiated by 360 direction(all direction) Light is converted to heat in the tissue. Attack only 3 mm each direction Maintain surrounding tissue less than 40 celcius Superior for vaporization and coagulation in the same time FDA and CE approved Promising outcome results in several well design studies. 2007, male 35 yr, MRI 6 months after PDCT.

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70 Future Intradiscal Therapies Fibrin glue Growth Factor Injection Cytokine Inhibitor Injection Autologous chondrocyte transplant Mesenchymal stem cell trnasplant

71 The aim: Current Ongoing Studies: Cell-Based Therapies To achieve cellular repair of the degenerated disc matrix. Approach To stimulate the disc cells to produce more matrix. To stimulate production Nucleus Pulposus cells S. Richardson, the University of Manchester He produced nucleus pulposus cells using mesenchymal stem cells (MSCs) Mixing the MSCs in a collagenous gel, and then implanting the gel in the intervertebral disc via an arthroscopic procedure. Experimental work demonstrates promising results.

72 Thank You

73 Sung Eun Sim, et al. Korean J Pain March;24(1):36-43.

74 Pre- and post-nucleoplasty Magnetic Resonance Imaging for a 65-year-old woman. Preoperative sagittal (A) and axial (B) images show the disc protrusion causing right neural for aminal stenosis at C6-7 intervertebral disc level. Postoperative sagittal (C) and axial (D) images do not show the evident volume reduction of protruded intervertebral disc segment. Sung Eun Sim, et al. Korean J Pain March;24(1):36-43.

75 Ramirez and Thisted reviewed 28,000 discectomy procedures with 1 in 64 patients having a major complication,1 in 335 having a neurological complication, nearly 1 in 500 having a cardiovascular complication, and 1 in 1,700 dying from the procedure.11,12 Ramirez LF, et al. Complications and demographic characteristics of patients undergoing lumbar discectomy in community hospitals. Neurosurgery 1989

76 Neucleoplasty Thermal Annular Procedure using RF technology RF electrical current is converted to heat in the tissue. Decompression of disc via ablation of nucleus Controlled tissue removal Minima invasive with a small cannula (1mm or 1/20th inch) to access the disc minimizing risk of recurrence Proven method of action with consistent outcome results (75%- 80% success)