Percutaneous disc decompression using nucleoplasty in patients with discogenic low back pain Poster No.: C-2358 Congress: ECR 2012 Type: Scientific Paper Authors: P. Nikolopoulos, P. Maniatis, A. P. Giannila, A. D. Kelekis, J. Papailiou, C. Triantopoulou; Athens/GR Keywords: Interventional non-vascular, Musculoskeletal spine, Neuroradiology spine, Fluoroscopy, Percutaneous, MR, Ablation procedures, Motility, Hernia DOI: 10.1594/ecr2012/C-2358 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. www.myesr.org Page 1 of 10
Purpose Open spine surgery for cases of symptomatic disc herniation producing persistent back and leg pain that is intractable to conservative therapy, may be followed by significant morbidity. Furthermore, poor results have been reported for contained disc herniations with open surgical interventions. Percutaneous treatments (table 1) in the therapy of discogenic low back pain and sciatica are used to reduce the intradiscal pressure in the nucleus thus reducing the irritation of the nerve root and the pain receptors in the annulus and the peridiscal space. Recently, coblation nucleoplasty has been added in the therapeutic options for patients with chronic low back pain. The purpose of this study is to report our initial experience and to assess the efficacy of nucleoplasty in treating patients with contained disc protrusion/herniation. Images for this section: Table 1: Current minimally invasive percutaneous intervertebral disc therapies. Page 2 of 10
Methods and Materials Thirteen patients (9 men and 4 women) with low back and leg pain underwent nucleoplasty in our department during the last 18 months, after failure of conservative therapy for at least 6 weeks. All patients had MRI proven small to medium size disc protrusion/herniation with preserved disk height of at least 50% (Fig 1). The coblation bipolar device (SpineWand, Arthrocare, USA) was introduced in the nucleus pulposus through a 17 Gauge Trocar (Crawford, 6", Arthrocare), positioned parallel to and at midway between the two end plates under fluoroscopic control (Fig 2,3). Radiofrequency driven molecular dissociation and removal of nuclear material at relatively low temperatures (typically 40 C to 70 C) was used to create six channels at the two, four, six, eight, ten and twelve o'clock positions, to ensure adequate decompression of the disc space, by slightly rotating the coblation electrode (Fig 4). Provocative discography was performed in 4 patients prior to the percutaneous disc decompression (Fig 5). Selective Neural Root Block was performed in all patients immediately after nucleoplasty with 1.0 ml of betamethasone sodium phosphate and betamethasone acetate (Celestone Chronodose) and 1.0 ml of Bupivacaine 0.5% (Fig 6,7). The visual analogue pain scale (VAS) was used to document the pain perception of patients before and up to 12 months following coblation. Follow up MRI to assess size disc protrusion/ herniation was performed at 3 months. Images for this section: Page 3 of 10
Fig. 1: Sagittal and axial T2-weighted images of lumbosacral spine show left paracentral disk protrusion with compression of left root at L4-5. Fig. 2: Trocar positioning performed under local anesthesia and fluoroscopic control at the L4-5 level, followed by the insertion of the coblation bipolar device. Annulus fibrosus puncture can be both felt and seen under fluoroscopy Page 4 of 10
Fig. 3: Trocar advancement at the L3-4 level is performed under fluoroscopic control at the Scotty dog projection. The inserted trocar must be inside the nucleus pulposus (projecting in posteroanterior view near the midline) parallel to and at midway between the two end plates. Page 5 of 10
Fig. 4: To and fro movement of the bipolar needle through the Trocar for 6 seconds, followed by slight rotation of the inner needle and repetition of coblation to form six channels inside the nucleus pulposus (at the two, four, six, eight, ten and twelve o'clock positions) to ensure adequate decompression of the disc space. Fig. 5: Provocative discography was performed by injecting contrast medium into the nucleus pulposus (L4-5 level) to confirm the diagnosis of discogenic pain with positive provocative elicitation of concordant pain (same as patient as in Fig 2). Page 6 of 10
Fig. 6: Selective right L3 nerve root block after coblation nucleoplasty (same patient as in Fig 3). Page 7 of 10
Fig. 7: Left L5 selective nerve root block post nucleoplasty. Page 8 of 10
Results Nucleoplasty was performed successfully in all cases, on an outpatient basis. All patients were monitored post-procedurally for 12 hours and then discharged with instructions not to perform lifting, bending or stooping. One week after the procedure, patients were permitted to return to light work while nonsteroidal anti-inflammatory drugs and muscle relaxants were prescribed. There were no complications associated with the procedure during follow-up period except from two patients reporting soreness at the needle insertion site, which resolved within 10 days. Significant amelioration of symptoms was seen in all patients in the immediate post-procedural period. Before the procedure, the mean value of VAS was 8,2±0,2 in low back and leg pain while the 6-month value was 2,90 ±0,2 and the 12-month value was 3,38 ±0,2. The improvement rates of VAS were 64.6% and 58.7% in 6 and 12 months respectively. Follow up MRI post procedurally revealed radiologic findings in correlation to the symptomatic improvement in all patients (Fig 8). Images for this section: Fig. 8: MRI of the same patient as in Fig 1 reveals post procedural tissue of low signal intensity in the anterolateral epidural space, with no depiction of the previously obvious left paracentral disk protrusion. Page 9 of 10
Conclusion Percutaneous nucleoplasty is a minimally invasive disc ablative technique with satisfactory clinical outcomes and low rate of complications for the treatment of discogenic low back pain and sciatica in a selected patient cohort. The small volumetric reduction of the nucleus pulposus after the application of radiofrequency energy results in a disproportionate decrease in pressure, hence relieving some of the chemical and mechanical factors causing pain. References 1. 2. 3. 4. 5. The efficacy of coblation nucleoplasty for protrusion of lumbar intervertebral disc at a two-year follow-up. Zhu H, Zhou XZ, Cheng MH, Shen YX, Dong QR. Int Orthop. 2011 Nov;35(11):1677-82 Standards of practice: quality assurance guidelines for percutaneous treatments of intervertebral discs. Kelekis AD, Filippiadis DK, Martin JB, Brountzos E. Cardiovasc Intervent Radiol. 2010 Oct;33(5):909-1 Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor. Singh V, Benyamin RM, Datta S, Falco FJ, Helm S 2nd, Manchikanti L, Pain Physician. 2009 May-Jun;12(3):589-99. A systematic review on the effectiveness of the Nucleoplasty procedure for discogenic pain. Gerges FJ, Lipsitz SR, Nedeljkovic SS. Pain Physician. 2010 Mar-Apr;13(2):117-32. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, Herkowitz H, Fischgrund J, Cammisa FP, Albert T, Deyo RA. JAMA. 2006 Nov 22;296(20):2451-9. Personal Information Page 10 of 10