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1 A prospective study comparing percutaneous decompression, combination of minimally invasive techniques and conservative therapy for the treatment of intervertebral disc herniation Poster No.: B-506 Congress: ECR 2011 Type: Topic: Scientific Paper Interventional Radiology Authors: D. K. Filippiadis, G. Velonakis, A. MAZIOTI, A. Malagari, N. Kelekis, A. Kelekis; Athens/GR Keywords: DOI: Interventional non-vascular, Spine, Musculoskeletal spine, Fluoroscopy, Percutaneous, Ablation procedures, Comparative studies, Treatment effects, Hernia, Pathology /ecr2011/B-506 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. Page 1 of 14

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3 Purpose Spinal disc disease (either with acute or progressive appearance of symptoms) in many cases may be self limited. The initiall therapy mode is a 4-6 weeks course of analgesics, muscle relaxants, nonsteroid anti-inflammatory drugs, immobilization, bed rest and physical therapy. Image guided, minimally invasive techniques percutaneously remove the nucleus pulposus by using a variety of thermal or mechanical techniques. Hijikata et all in 1975 stated that: "Reduction of intradiscal pressure, reduced the irritation of the nerve root and the pain receptors in the annulus and peridiscal area". Based on this principle minimallly invasive techniques remove all or part of nucleus pulposus to induce more rapid healing of the abnormal lumbar disc. The purpose of our study is to compare mean short, intermediate and long term functional results concerning pain reduction and mobility improvement between conservative therapy, percutaneous disc decompression (PDD) and combination of minimally invasive techniques for intervertebral disc herniation treatment. Methods and Materials During the last 4 years we prospectively compared 3 groups of 15 patients each, suffering from sciatica due to intervertebral disc herniation. Group A underwent fluoroscopically guided percutaneous intervertebral disc decompression (PDD) [Fig. 1]. on page 4 Group B underwent a session where PDD was combined either to intradiscal discogel infusion, or to percutaneous nucleoplasty (plasma energy coblation). Group C underwent conservative therapy (analgesics, anti-inflammatory drugs, muscle relaxants, physiotherapy) for 6 weeks. Pain reduction and mobility improvement were recorded [clinical evaluation, 0-10 units Numeric Visual Scale (NVS)] prior and at 3, 12, 24 months post therapy in each group. Page 3 of 14

4 TECHNIQUE Image guided minimally invasive techniques were performed under extensive local sterility measures, pre-procedural antibiotic therapy administration and local therapy. With the patient in prone position, under fluoroscopy guidance and posterolateral approach at the Scottie dog projection the disc of interest was punctured. Once the trocar was inside nucleus pulposus, at its desired final position (parallel to and at midway between the two endplates) the needle was removed [FIG. 2]. on page 4 Through the trocar the chosen decompressive or ablative device was introduced. In selected cases CT scan was performed immediately after the session [FIG. 3]. on page 5 Images for this section: Fig. 1: The two spiral components of the decompressor promote disc removal during rotation. Page 4 of 14

5 Fig. 2: The desired final position of the trocar is at the frontal disc third (on lateral projection) and at midline (on P-A projection)parallel to and at midway between the two endplates. Page 5 of 14

6 Fig. 3: CT scan (saggittal and axial reconstructions) of a patient (not included in our study)suffering from C5-C6 herniation treated with combination of PDD and discogel intradiscal injection. Notice the presence of discogel as well as of an air bubble within the herniation. Page 6 of 14

7 Results Values of pain reduction in the patients of the 3 groups throughout the follow-up period are shown in detail on Chart 1. on page 7 Values of pain reduction in percentage among the patients of the 3 groups throughout the follow-up period are shown in detail on Chart 2. on page 8 Within a 24 months follow-up period, Group A patients presented a mean pain reduction of 6.60±3.31 NVS units (80.38% success rate). Group B patients a mean pain reduction of 5.73±2.60 NVS units (76.82% success rate). Group C patients presented a mean pain reduction of 2.33±2.94 NVS units (34.30% success rate). No complications were noted. Comparison of pain reduction among Group A, B and C at 3 months post therapy was not statistically significant. Comparison of pain reduction among Group A and Group C at 12 and 24 months is statistically significant (p=0.022 and p=0.005 respectively). Comparison of pain reduction among Group B and Group C at 12 and 24 months is statistically significant (p=0.033 and p=0.004 respectively). Comparison of pain reduction among Group A and Group B at 12 and 24 months is not statistically significant (p=0.43). Images for this section: Page 7 of 14

8 Fig. 1: Chart 1 shows the mean values of pain reduction among the patients of the 3 groups throughout the follow-up period. Page 8 of 14

9 Fig. 2: Chart 2 shows the mean values of pain reduction (in percentage) among the patients of the 3 groups throughout the follow-up period. Page 9 of 14

10 Conclusion Presence of comparative groups enables us to illustrate detailed differents among the efficacy of various treatment modes for the therapy of small to medium sized intervertebral disc hernias. In this prospective randomized study of patients with symptomatic intervertebral disc herniation, all therapy groups improved considerably within the 2 years follow-up period. Nevertheless, patients who underwent percutaneous image-guided, minimally invasive techniques (performed either solely or in combination) had statistically significant better self-reported outcomes than those who had conservative therapy at 12 and 24 months of the follow-up period. There is no proof that combining minimally invasive techniques will improve the success rate. Images for this section: Page 10 of 14

11 Fig. 1: Chart 1 shows the mean values of pain reduction among the patients of the 3 groups throughout the follow-up period. Page 11 of 14

12 Fig. 2: Chart 2 shows the mean values of pain reduction (in percentage) among the patients of the 3 groups throughout the follow-up period. Page 12 of 14

13 References 1. Kelekis AD, Filippiadis DK, Martin JB, Brountzos E. Standards of practice: Quality assurance guidelines for percutaneous treatments of intervertebral discs. Cardiovasc Intervent Radiol (2010) 33: Andersson G.B.J. Epidemiological features of chronic low-back pain. Lancet 1999; 354: Kennedy M. IDET: A new approach to treating lower back pain. WMJ (1999): 98: Anderson S.R., Flanagan B. Discography. Curr Rev Pain (2000); 4: Coppes M.H., Marani E., Thormeer R.T.W.M., Groen G.J. Innervation of "painful" lumbar discs. Spine (1997); 22: Schwarzer A.C., April C.N., Derby R. The prevelance and clinical feature of internal disc disruption of patients with chronic low back pain. Spine (1995); 20: Manchikanti L., Singh V., Pampati V. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician (2001); 4; Kelekis, A.D., T. Somon, H. Yilmaz, P. Bize, E.N. Brountzos, K. Lovblad, D. Ruefenacht, and J.B. Martin. Interventional spine procedures. European journal of radiology, 2005; 55: Shah R.V., Everett C.E., McKenzie-Brown A.M., Seghal N. Discography as a diagnostic test for spinal pain: a systematic and narrative review. Pain Phys 2005; 8: Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Phys 2006;9: Choy, D.S.J., P.W. Ascher, and S. Saddekni, Percutaneous laser disc decompressions: A new therapeutic modality. Spine, : p Personal Information Alexis D. Kelekis Assistant Proffessor of Diagnostic and Interventional Radiology 2nd Radiology Department, University General Hospital "ATTIKON", Athens/GR akelekis@med.uoa.gr Dimitrios K. Filippiadis Page 13 of 14

14 Interventional Radiologist - Consultant Research and Medical Imaging Unit, University General Clinic "EVGENIDION", Athens/ GR dfilippiadis@yahoo.gr Page 14 of 14