Past, Present, and Future of Therapeutic Lumbar Spine Interventional Procedures

Image-guided percutaneous mechanical disc decompression for herniated discs: a technical note

Interventional radiology plays a key role in the treatment of symptomatic herniations of intervertebral discs. Through image-guided techniques, it is possible to use minimally invasive procedures with a percutaneous approach that are usually proposed before classic surgery. Thanks to imaging guidance, it is possible to significantly increase accuracy and decrease complication rates. The pivotal principle of these mini-invasive techniques is to remove a small amount of volume of the nucleus of the intervertebral disc which results in a significant reduction in intradiscal pressure; allowing for a consequent reduction in compression of the nervous structures that generate spinal pain. However, it must be considered that this type of treatment is only addressed to contained disc herniations previously diagnosed with a suitable neuroimaging examination. There are different types of treatment using a variety of chemical, thermal or mechanical processes that result in partial removal of the nucleus pulposus. The purpose of this technical note is to illustrate mechanical disc decompression treatment via a percutaneous approach using the DISKOM device (DISKOM percutaneous discectomy probe, Biopsybell, Mirandola, Italy). Indications, complications and various methods of use are described in relation to the different levels of the spine to be treated.

MR epidurography: distribution of injectate at caudal epidural injection

OBJECTIVE

To (a) evaluate the feasibility of MR epidurography (MRE) and (b) assess the distribution of injectate using two different volumes at caudal epidural steroid injection.

MATERIALS AND METHODS

Twenty patients who were referred with symptomatic low back pain for caudal epidural steroid injection were assigned to have either 10 ml (9/20) or 20 ml (11/20) of injectate administered. Gadolinium was included in the injection. The patients proceeded to MRI where sagittal and coronal T1-weighted fat-saturated sequences were acquired and reviewed in the mid-sagittal and right and left parasagittal views at the level of the exit foramina.

RESULTS

Gadolinium was observed at or above the L3/4 disc level in all 11 patients who received 20 ml (100 %), compared with only five of nine patients who received 10 ml (56 %). Injectate was seen to the L4 nerve root level in all 11 patients who received 20 ml (100 %) but only four out of nine patients who received 10 ml (44 %), not even reaching the L5 nerve root level in four further of these nine patients (44 %). Overall, there was a trend to visualize gadolinium at higher levels of the epidural space with higher volumes injected.

CONCLUSIONS

Firstly, MR epidurography is a safe technique that allows excellent visualization of the distribution of gadolinium in the epidural space following injection via the caudal hiatus. Secondly, a volume of 10 ml is unlikely to treat L5/S1 disease in almost half of patients at caudal epidural steroid injection and at least 20 ml of injectate is likely required for any medication to reach the desired level.

Efficacy of therapeutic fluoroscopy-guided lumbar spine interventional procedures

PURPOSE

To evaluate the benefit of fluoroscopy-guided lumbar spine interventional procedures in treatment of low back pain.

METHODS

This prospective descriptive study was performed on 60 patients with back/radicular pain after showing no improvement with conservative treatment.

RESULTS

One hundred and two injection sessions were done (average 1.7 injection per patient). Caudal and lumbar transforaminal injections were effective in 55.9% and 78.5%, respectively. Facet and sacroiliac interventions were effective in 28.3% and 10%, respectively. Complications occurred in 20% of the procedures.

CONCLUSION

Lumbar injections improved pain/disability related to discogenic lumbar spinal diseases. Efficacy of facet and sacroiliac injections is limited.

Standards of practice: quality assurance guidelines for percutaneous treatments of intervertebral discs

Percutaneous treatments are used in the therapy of small- to medium-sized hernias of intervertebral discs to reduce the intradiscal pressure in the nucleus and theoretically create space for the herniated fragment to implode inward, thus reducing pain and improving mobility and quality of life. These techniques involve the percutaneous removal of the nucleus pulposus by using a variety of chemical, thermal, or mechanical techniques and consist of removal of all or part of nucleus pulposus to induce more rapid healing of the abnormal lumbar disc. These guidelines are written to be used in quality improvement programs for assessing fluoroscopy- and/or computed tomography-guided percutaneous intervertebral disc ablative techniques.