Rome, 9-11 July MASSIMO GALLUCCI Neuroradiology Unit,, University-Hospital L AquilaL. Aquila- ITALY massimo.gallucci

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1 Rome, 9-11 July 2009 MASSIMO GALLUCCI Neuroradiology Unit,, University-Hospital L AquilaL Aquila- ITALY massimo.gallucci gallucci@cc.univaq.itit

2 BEFORE AFTER

3 Diagnostic Knowledge: main need for being a Spine Interventionist Clinical and Diagnostic knowledge Main Disease Natural history Differential diagnoses Mimics Pharmaceutical Knowledge Complications Follow-up

4 Lumbar disk herniation natural history Favorable outcome in most of cases Pearce J, Moll JMC, J Neurol Neurosurg Psych 30, 1967: Saal JA, Saal JS, Spine 14, 1989: Bozzao A, Gallucci M et al., Radiology 185,1992, Bush K, Coman N, et al., Spine 10, 1992,

5 Radiology 185,1992,

6 WHICH MECHANISM HELPS IN DISC HERNIATION INVOLUTION Coma Rest in bed Conventional myelography Fear of Neurosurgery None of the above. It just happens DECISION! Follow up study on 100 Pts.

7 THE ANATOMICAL HISTORY OF DISC HERNIATION * Partial or complete regression = 67-76% Same = 29-21% Worsening = 8-3 % * follow-up = 1 yr. Bozzao A, Gallucci M et al., Radiology 185,1992, Bush K, Coman N, et al., Spine 10, 1992,

8 THE NATURAL HISTORY OF DISK BULGING AND PROTRUSION* Disk bulging = no changes Protrusion = 26% of partial or complete regression * follow-up = 1 yr. Bush K, Coman N, et al., Spine 10,1992, Personal data

9 MECHANISMS OF ANATOMICAL REGRESSION 1 HERNIATED MATERIAL DETATCHED FROM NUCLEUS Interruption of water (proteoglycan) supply Dehydration, shrinkage, fragmentation Tear of the annulus scar Lindblom K, Hultqvist G, J Bone Joint Surg 32a, 1950: Masaryk TJ, Ross JS et al.,ajnr 9,1988,

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12 MECHANISMS OF ANATOMICAL REGRESSION 2 HERNIATED MATERIAL DETATCHED FROM NUCLEUS Antigenically segregated material (nucleus) Activation of inflammatory response Granulation tissue and newly formed vessels Infiltration and phagocytosis Tear of the annulus scar Eckert J, JBJS 29, Lindblom K, JBJS, 32A Brock M, Spine 17, Yasuma T, Spine 18,

13 DISK FRAGMENT PHAGOCYTOSIS * Early peripheral enhancement in % * Enhancement of herniation in 1-2 months * Persistence of enhancement and shrinkage in 6-12 months Ross Js, et al, AJNR 1990, Doows GC et al, ESNR Ross JS, et al AJNR * Gallucci M, et al. JCAT 19, Hwang GJ, et al. J Mag Res Imaging, 1997, 7:

14 after 3 months

15 Gallucci M, et al. JCAT 19,

16 CONSERVATIVE TREATMENT 1. Free fragments (regression in %) 2. Peripheral enhancement ( 80 %) 3. Recent clinical onset (2-3-weeks) ( 75 %) 4. T2-w hyperintense extrusions ( in 68 %) 5. No relationship with dimension, location, site Gallucci M, et al. JCAT 19, (1,2) Splendiani A, et al. Neuroradiology 2004, 46: (1-4) Modic MT, et al Radiology 2005;237: (5) Cribb GL, wt al. J Bone Surg Br 2007, (1)

17 Percutaneous Approach: why? CONSERVATIVE TREATMENT REGRESSION-REDUCTION OF SYMPTOMS 34,7 % after 6 months 67 % after 1 year Bozzao A, Gallucci M et al., Radiology 185,1992, Splendiani A, Gallucci M. et al. Neuroradiology 2004, 46: CLINICAL COURSE AFTER O2-O3 TREATMENT REGRESSION-REDUCTION OF SYMPTOMS 87 % after 15 days 74 after 6 months 71 % after 1 year Gallucci M et al, Radiology 2007, 242 (3)

18 Percutaneous Approach: why? - Limits of Open Surgery: 1. Treatment failure: 5-15% 2. Complication rate: 2.2-5% 3. Long Distance follow-up: comparable results between treated and untrated after 10 yrs (10-25% recurrences) 4. Comparable results between surgery and microinterventions at 3 and 12 months -Limits of microinterventions: 1. treatment failure: 10-40% 2. complication rate: statistically irrelevant Davis RA, J Neurosurg Mar;80(3): Atlas SJ, et al, Spine , , Weinstein JN, et al, JAMA , Wu Z., et al. Eur J Radiol. 2008, 6.

19 CONSERVATIVE TREATMENT REGRESSION-REDUCTION OF SYMPTOMS 34,7 % after 6 months 67 % after 1 year Bozzao A, Gallucci M et al., Radiology 185,1992, Splendiani A, Gallucci M. et al. Neuroradiology 2004, 46: CLINICAL COURSE AFTER O2-O3 TREATMENT REGRESSION-REDUCTION OF SYMPTOMS 87 % after 15 days 74 after 6 months 71 % after 1 year Gallucci M et al, Radiology 2007, 242 (3) Last but not least no contraindication in doing open surgery in case of clinical insuccess

20 Treatment Aims CONSERVATIVE TREATMENT CLINICAL COURSE AFTER O2-O3 TREATMENT REGRESSION-REDUCTION OF REGRESSION-REDUCTION OF SYMPTOMS SYMPTOMS 87 % after 15 days 34,7 % after 6 months 74 after 6 months 67 % after 1 year 71 % after 1 year Bozzao A, Gallucci M et al., Radiology 185,1992, Splendiani A, Gallucci M. et al. Neuroradiology 2004, 46: Gallucci M et al, Radiology 2007, 242 (3) LEVEL GOAL OF THE TREATMENT: Reduce symptoms during the first 4-6 months and let the natural history have its course

21 Percutaneous Approach: why? Medico-Legal aspects INFORMED CONSENT: The Pt. MUST be informed about the risk/benefit of the proposed therapy and about possible alternative treatments.

22 Percutaneous Approach: why? Economical Aspect Cost/Effectiveness over 2 years: Surgery was more costly than non-operative care. The mean difference was usd 14,134 (100% more), however those who choose interventions reported greater improvements Percutaneous treatments cost about half of the surgical ones Tosteson AN et al, Spine 2008, Sept. 1; 33 (19):

23 How to treat? Minimally invasive treatments Epidural steroid injection Perigangliar steroid injection Papain chemonucleolysis Percutaneous discectomy (Onik) Mechanical decompression RF nucleoplasty IDET Laser Alcoholization Oxygen-ozone discolysis

24 RF LASER O2-O3 ALCOOL- GEL NEEDLE 17 GAUGE 18 GAUGE GAUGE 20 GAUGE TIME (needle in site) 2min 15 min Few seconds Few seconds MECH. OF ACTION Coblation Vaporization Micro and Macro Vacuolization Extended Necrosis COMPLI CATIONS None? 2% (Gangi, 2007) 3% None None COST OF SINGLE TREATM

25 Needs for being a perfect spine interventionist Chap.2: skill Competence in handling percutaneous devices Competence in fluoroscopic/ct guidance Knowledge+Skill = Risk/Benefit Clinical knowledge = Spine Skill = Radiology CLINICAL RADIOLOGIST

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