Management of chronic discogenic low back pain with a thermal intradiscal catheter. A preliminary report

Anatomic zone division and clinical significance of the lumbar sinuvertebral nerves

BACKGROUND CONTEXT

Discogenic low-back pain (DLBP) is one of the primary causes of low back pain (LBP) and is associated with internal disk disruptions and is mainly transmitted by the sinuvertebral nerve (SVN). The lack of a universal understanding of the anatomical characteristics of the SVN has compromised surgical treatment for DLPB.

PURPOSE

This study aims to elaborate on the anatomical characteristics of the SVN and to discuss their possible clinical significance.

STUDY DESIGN

The SVNs were dissected and immunostained in ten human lumbar specimens.

METHODS

The SVNs at the segments from L1-L2 to L5-S1 in ten human cadavers were studied, and the number, origin, course, diameter, anastomotic branches, and branching points of the SVNs were documented. Three longitudinal and five transverse zones were defined in the dorsal coronal plane of the vertebral body and disc. The vertebrae were divided longitudinally as follows: the region between the medial edges of the bilateral pedicles is divided into three equal parts, the middle third is zone I and the lateral third on both sides are zones II; the areas lateral to the medial margin of the pedicle were zones Ⅲ.The transverse zones were designated as follows: a)superior margin of the vertebral body to superior margin of the pedicle; b) between superior and inferior margins of the pedicle; c) inferior margin of the pedicle to inferior margin of the vertebral body; d) superior margin of the disc to the midline of the disc; and e) midline of the disc to the inferior margin of the disc. The distribution characteristics of SVNs in various zones were recorded, and tissue sections were immunostained with anti-NF 200 and anti-PGP 9.5.

RESULTS

The SVNs are divided into main trunks and deputy branches, with 109 main trunks and 451 deputy branches identified in the 100 lumbar intervertebral foramens (IVFs). The main trunks of the SVN originate from the spinal nerve and/or the communicating branch, but the deputy branch originating from both roots was not observed. All the main trunks and deputy branches of the SVNs originate from the posterolateral disc (Ⅲ d and Ⅲ e). The deputy branches of the SVN primarily innervate the posterolateral aspect of the intervertebral disc (Ⅲ d 46.78%, Ⅲ e 36.36%) and the subpedicular vertebral body (Ⅲ c 16.85%). The main trunk of the SVNs passes primarily through the subpedicular vertebral body (Ⅲ c 96.33%) and divides into ascending, transverse, and descending branches in the IVF: Ⅲ c (23/101, 22.77%) or spinal canal: Ⅱ c (73/101, 72.28%), Ⅱ d (3/101, 2.97%), Ⅱ b (2/101, 1.98%). The main trunk possesses extensive innervation, and except for the most medial discs (Ⅰ d and Ⅰ e), it almost dominates all other zones of the spinal canal. At the segments from L1-L2 to L5-S1, 39 ipsilateral anastomoses connecting the ascending branch to the main trunk or spinal nerve at the upper level were observed, with one contralateral anastomosis observed at L5.

CONCLUSION

The zone distribution characteristics of SVNs are similar across all levels. Comparatively, the proportion of double-root origin and the number of insertion points of the SVNs increased at the lower level. The three types of anastomosis offer connections between SVNs at the same level and at different levels. The posteromedial disc is innervated by corresponding and subjacent main trunks, with the posterolateral disc mainly innervated by the deputy branch.

CLINICAL SIGNIFICANCE

Detailed information and zone distribution characteristics of the lumbar SVNs can help improve clinicians' understanding of DLBP and improve the effectiveness of treatments targeting the SVNs.

Intervertebral Disc Degeneration: Biomaterials and Tissue Engineering Strategies toward Precision Medicine

Intervertebral disc degeneration is a common cause of discogenic low back pain resulting in significant disability. Current conservative or surgical intervention treatments do not reverse the underlying disc degeneration or regenerate the disc. Biomaterial-based tissue engineering strategies exhibit the potential to regenerate the disc due to their capacity to modulate local tissue responses, maintain the disc phenotype, attain biochemical homeostasis, promote anatomical tissue repair, and provide functional mechanical support. Despite preliminary positive results in preclinical models, these approaches have limited success in clinical trials as they fail to address discogenic pain. This review gives insights into the understanding of intervertebral disc pathology, the emerging concept of precision medicine, and the rationale of personalized biomaterial-based tissue engineering tailored to the severity of the disease targeting early, mild, or severe degeneration, thereby enhancing the efficacy of the treatment for disc regeneration and ultimately to alleviate discogenic pain. Further research is required to assess the relationship between disc degeneration and lower back pain for developing future clinically relevant therapeutic interventions targeted towards the subgroup of degenerative disc disease patients.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

Therapeutic effect of intradiscal pulsed radiofrequency on internal disc disruption: A case report

RATIONALE

Discogenic low back pain often persists despite medication and medical intervention. In this study, intradiscal pulsed radiofrequency (PRF) was performed in a patient with discogenic low back pain who did not respond to oral medication, posterior medial branch block, epidural steroid injection, and percutaneous epidural adhesiolysis.

PATIENT CONCERNS

A 28-year-old woman visited a pain clinic complaining of low back pain that was scored 8 out of 10 on a numerical rating scale. Her pain was present in any position throughout the day and worsened in the sitting position.

DIAGNOSES

Magnetic resonance imaging showed L5-S1 internal discal disruption. Based on the medical history, physical examination, and magnetic resonance imaging, we determined that her pain originated from the L5-S1 disc.

INTERVENTIONS

We performed an intradiscal PRF on the affected disc under C-arm fluoroscopy guidance. PRF was performed at 5 Hz, 20-ms pulse width, and 70 V for 15 minutes while ensuring that the electrode tip temperature was maintained below 42°C.

OUTCOMES

Immediately after the procedure, the patient's pain subsided. At the 1-month follow-up visit, the patient reported complete relief of her low back pain. The Oswestry disability index, which indicates the degree of disability, improved significantly. She also reported that she could sit for long periods because the pain was reduced. No adverse effects from the procedure were found.

LESSONS

Applying intradiscal PRF seems an effective and safe technique for treating discogenic low back pain.

A Comprehensive Update of the Treatment and Management of Bertolotti's Syndrome: A Best Practices Review

Bertolotti's Syndrome is defined as chronic back pain caused by transitional lumbosacral vertebra. The transitional vertebra may present with numerous clinical manifestations leading to a myriad of associated pain types. The most common is pain in the sacroiliac joint, groin, and hip region and may or may not be associated with radiculopathy. Diagnosis is made through a combination of clinical presentations and imaging studies and falls into one of four types. The incidence of transitional vertebra has a reported incidence between 4 and 36%; however, Bertolotti's Syndrome is only diagnosed when the cause of pain is attributed to this transitional anatomy. Therefore, the actual incidence is difficult to determine. Initial management with conservative treatment includes medical management and physical therapy. Injection therapy has been established as an effective second line. Epidural steroid injection at the level of the transitional articulation is effective, with either local anesthetics alone or in combination with steroids. Surgery carries higher risks and is reserved for patients failing previous lines of treatment. Options include surgical removal of the transitional segment, decompression of stenosed foramina, and spinal fusion. Recent evidence suggests that radiofrequency ablation (RFA) around the transitional segment may also provide relief. This manuscript is a comprehensive review of the literature related to Bertolotti's Syndrome. It describes the background, including epidemiology, pathophysiology, and etiology of the Syndrome, and presents the best evidence available regarding management options. Bertolotti's Syndrome is considered an uncommon cause of chronic back pain, though the actual incidence is unclear. Most evidence supporting these therapies is of lower-level evidence with small cohorts, and more extensive studies are required to provide strong evidence supporting best practices.

MR-Guided Percutaneous Intradiscal Thermotherapy (MRgPIT): Evaluation of a New Technique for the Treatment of Degenerative Disc Disease in Cadaveric Lumbar Spine

PURPOSE

Evaluation of MR feasibility and real-time control of an innovative thermoablative applicator for intradiscal thermotherapy and histological analysis of laser annuloplasty in human ex vivo intervertebral discs.

MATERIALS AND METHODS

We evaluated a new MR-compatible applicator system for MR-guided percutaneous intradiscal thermotherapy (MRgPIT) in an open 1.0-T MRI-system. Needle artefacts and contrast-to-noise ratios (CNR) of six interactive sequences (PD-, T1-, T2w TSE, T1-, T2w GRE, bSSFP) with varying echo-times (TE) and needle orientations to the main magnetic field (B₀) were analysed. Additionally, five laser protocols (Nd: YAG Laser, 2-6 W) were assessed in 50 ex vivo human intervertebral discs with subsequent histological evaluation.

RESULTS

In vitro, we found optimal needle artefacts of 1.5-5 mm for the PDw TSE sequence in all angles of the applicator system to B₀. A TE of 20 ms yielded the best CNR. Ex vivo, ablating with 5 W induced histological denaturation of collagen at the dorsal annulus, correlating with a rise in temperature to at least 60 °C. The MRgPIT procedure was feasible with an average intervention time of 17.1 ± 5.7 min.

CONCLUSION

Real-time MR-guided positioning of the MRgPIT-applicator in cadaveric intervertebral disc is feasible and precise using fast TSE sequence designs. Laser-induced denaturation of collagen in the dorsal annulus fibrosus proved to be accurate.

Advanced Image-Guided Procedures for Painful Spine

In addition to basic image-guided injections, there are many advanced procedures to address the challenges of spine pain. Patients with debilitating symptoms are offered relief, a shorter recovery period, and fewer potential complications. Pain arises from numerous sites along the spine, presenting as spine pain or radiculopathy. This article is an overview of advanced techniques in this rapidly progressing field, including neuromodulation, radiofrequency thermocoagulation, discography, intradiscal thermocoagulation, and percutaneous image-guided lumbar decompression; and it highlights etiologic factors and their relationship to therapeutic technique and clinical evidence.

Thermal-Induced Osteonecrosis of Adjacent Vertebra after Intradiscal Electrothermal Therapy

A 42-year-old man was admitted to our hospital with complaints of low back pain and intermittent right thigh pain. Twelve weeks before admission, the patient received intradiscal electrothermal therapy (IDET) at a local hospital. The patient still reported low back pain after the procedure that was managed with narcotic analgesics. Follow-up magnetic resonance imaging (MRI) was performed, and his referring physician thought the likely diagnosis was spondylodiscitis at the L4–5 spinal segment with a small epidural abscess. At admission to our department, the patient reported aggravated low back pain. Blood test results, including the erythrocyte sedimentation rate and C-reactive protein levels, were slightly elevated. Biopsy samples of the L4, L5 vertebral bodies and disk were obtained. The material underwent aerobic, anaerobic, fungal, mycobacterial cultures and histologic examination. Results of all cultures were negative. Histologically, necrosis of the bone was evident from the number of empty osteocyte lacunae. In addition, there was no evidence of infection based on biopsy results. No antibiotic treatment was administered on discharge. Repeat computed tomography and MRI performed 12 months after IDET showed a bony defect in the L4 and L5 vertebral bodies, and a decrease in the size of the L4–5 intervertebral disc lesion. We report a case of lumbar vertebral osteonecrosis induced by IDET and discuss etiology and radiologic features.

Temperature Distributions of the Lumbar Intervertebral Disc during Laser Annuloplasty : A Cadaveric Study

Objective

Low back pain, caused intervertebral disc degeneration has been treated by thermal annuloplasty procedure, which is a non-surgical treatement. The theoretical backgrounds of the annuloplasty are thermal destruct of nociceptor and denaturization of collagen fiber to induce contraction, to shrink annulus and thus enhancing stability. This study is about temperature and its distribution during thermal annuloplasty using 1414 nm Nd : YAG laser.

Methods

Thermal annuloplasty was performed on fresh human cadaveric lumbar spine with 20 intact intervertebral discs in a 37℃ circulating water bath using newly developed 1414 nm Nd : YAG laser. Five thermocouples were attached to different locations on the disc, and at the same time, temperature during annuloplasty was measured and analyzed.

Results

Thermal probe's temperature was higher in locations closer to laser fiber tip and on lateral locations, rather than the in depth locations. In accordance with the laser fiber tip and the depth, temperatures above 45.0℃ was measured in 3.0 mm depth which trigger nociceptive ablation in 16 levels (80%), in accordance with the laser fiber end tip and laterality, every measurement had above 45.0℃, and also was measured temperature over 60.0℃, which can trigger collagen denaturation at 16 levels (80%).

Conclusion

When thermal annuloplasty is needed in a selective lesion, annuloplasty using a 1414 nm Nd : YAG laser can be one of the treatment options.

Lumbar lateral shift in a patient with interspinous device implantation: a case report

BACKGROUND

Lumbar lateral shift (LLS) is a common clinical observation but has rarely been described in a patient with a history of lumbar surgery. The purpose of the current case report was to describe the use of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) in the multi-modal treatment of a patient with an LLS and a history of multiple surgical procedures in the lumbar spine, including interspinous process device (IPD) implantation.

CASE DESCRIPTION

A 72-year-old female with chronic low back pain (LBP) and a surgical history in the lumbar spine was referred to physical therapy for radiating leg pain and presented with a right LLS. Her chief complaints included sitting for long periods, vacuuming and ascending stairs into her home.

OUTCOMES

The patient was treated during eight visits over 30 days. Treatment interventions included manual shift correction, self-correction and management, joint mobilisation below the level of IPD implantation ,neurophysiology education, and development of a home exercise programme. At discharge, her leg pain was resolved and all goals had been met. The patient reported maintenance of gains at 6-month follow-up.

DISCUSSION

Utilisation of the MDT approach, including LLS correction, produced positive outcomes in a complex patient with previous IPD implantation. Future research should investigate treatment and outcomes after invasive spinal procedures in similar patient populations to better inform clinical management.

LEVEL OF EVIDENCE

4.

[Interventions on the intervertebral discs. Indications, techniques and evidence levels]

CLINICAL ISSUE

Over the last decades a number of different minimally invasive interventions have been proposed for the treatment of intervertebral disc herniation and degeneration. All of these interventions aim at relieving pressure from compressed nerve roots by mechanical ablation, chemical dissolution, evaporation or coagulation of disc tissue.

STANDARD TREATMENT

Microsurgical sequestrectomy with direct visualization of the spinal canal.

TREATMENT INNOVATIONS

Minimally invasive intradiscal interventions, such as chemonucleolysis, manual and automated disc decompression, laser disc decompression, nucleoplasty and thermal anular radiofrequency (RF) techniques with posterolateral access to the intervertebral disc.

PERFORMANCE

The effectiveness and safety of the different minimally invasive procedures are compared to the standard surgical procedure on the basis of a literature review.

ACHIEVEMENTS

For patients with disc herniation requiring surgery, microsurgical sequestrectomy is the treatment of choice, while discectomy is obsolete. Intradiscal procedures have a low level of evidence while long-term results are still lacking. Randomized controlled trials are required to generate evidence-based results.

PRACTICAL RECOMMENDATIONS

Indications for treatment should be established by an interdisciplinary team with the choice of treatment depending on the interventionalist's expertise and skills. In carefully selected patients scheduled for elective treatment, the different minimally invasive procedures allow adequate treatment when performed by an experienced interventionalist.

Efficacy of coblation annuloplasty in discogenic low back pain: a prospective observational study

In degenerative disc, the innervated outer annulus is confirmed to the major origin resulted in discogenic pain. To alleviate the discogenic pain, annuloplasty with electrothermal technology was proved to be effective, which mainly involves the thermal heating of the annulus to denature collagen fibers and denervate posterior annular nerve fibers. However, little is known that efficacy of annuloplasty with coblation technology in treating discogenic pain through directly interrupting nerves in outer annulus.The purpose of this study was to evaluate the clinical outcomes of coblation annuloplasty for the treatment of discogenic low back pain.In a clinical prospective observational study, 17 consecutive patients with discogenic low back pain underwent coblation annuloplasty under local anesthesia. Pain visual analogue scale (VAS) scores, patient responses stating significant (≥50%) pain relief, and modified MacNab criteria were adopted to evaluate the pain intensity, degree of pain relief, and functional status after 6 months of follow-up.The preoperative pain VAS score was 6.5 ± 0.8(95% confidence interval [CI] 6.1-6.9) and the pain VAS score decreased to 2.9 ± 1.6 (95% CI 2.1-3.8), 2.9 ± 1.7 (95% CI 2.1-3.8), 3.2 ± 1.6 (95% CI 2.4-4.1), 3.2 ± 1.7 (95% CI 2.4-4.2) at 1 week and 1, 3 and 6 month postoperatively, respectively. 12 (70.6%), 11 (64.7%), 10 (58.8%) and 10 (58.8%) of patients reported significant pain relief at 1 week and 1, 3 and 6 months postoperatively. At 1, 3, and 6 months postoperatively, the numbers of patients with "excellent" or "good" ratings were 13 (76.5%), 11 (64.7%), and 10 (58.8%) according to the modified MacNab criteria. No serious complications were observed.The finds show that coblation annuloplasty is an effective, safe, and less uncomfortable procedure in managing discogenic low back pain.

Intradiscal electrothermal therapy treatment for back pain

The intradiscal electrothermal therapy (IDET) procedure is a minimally invasive technique designed to treat discogenic chronic low back pain. The debate surrounding IDET ranges from the concept of the procedure, the technique and patient selection, to its effectiveness. The procedure provides modest improvement; however, it is considered less invasive and destructive than other modalities of treatments available at the present time, and has lower cost. The effectiveness evidence is limited at the present time, but based on the results of six recently published positive single-arm studies, it appears that patients experienced a perceptible clinical benefit from the IDET procedure. Thus, IDET is recommended in patients with moderate functional impairment, relatively well-maintained disc heights and discogenic pain caused by annular tears or protrusions less than 3-4 mm after the failure of less invasive procedures.

Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature

BACKGROUND CONTEXT

Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology.

PURPOSE

In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain.

STUDY DESIGN

A systematic review of the recent literature.

METHODS

A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patient's pain and was the main target of the treatment, were retained for further analysis.

RESULTS

The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain.

CONCLUSIONS

Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.

Intradiscal injection therapy for degenerative chronic discogenic low back pain with end plate Modic changes

BACKGROUND CONTEXT

The effect of intradiscal steroid therapy for patients with degenerative chronic discogenic low back pain remains an issue of debate.

PURPOSE

To evaluate the effect of various intradiscal injection regimens for patients with degenerative chronic discogenic low back pain and end plate Modic changes.

STUDY DESIGN

Double-blind, randomized, controlled, prospective clinical study.

PATIENT SAMPLE

One hundred twenty patients with discogenic low back pain and end plate Modic changes on magnetic resonance imaging (MRI) who received discography but were unwilling to accept surgical operation.

OUTCOME MEASURES

Pain and function were determined by the visual analog scale (VAS) and the Oswestry Disability Index (ODI) assessment.

METHODS

Patients who received diagnostic discography for suspected degenerative discogenic low back pain were recruited. A total of 120 patients with positive discography and end plate Modic changes at a single level were enrolled in the study and allocated into Groups A and B according to the type of Modic changes on MRI. Then, the patients in Groups A and B were randomized into three subgroups, respectively. Intradiscal injection of normal saline was performed in Subgroups A1 and B1, intradiscal injection of diprospan was performed in Subgroups A2 and B2, and intradiscal injection of a mixed solution of diprospan+songmeile (cervus and cucumis polypeptide) was performed in Subgroups A3 and B3. The clinical outcome of each patient was evaluated and recorded by using the VAS and ODI at 3 and 6 months after the procedure.

RESULTS

The subgroups were comparable with respect to gender, age, pain, and percentage disability. Neither VAS pain scores nor Oswestry function scores of the patients within Group A had any improvement at 3 or 6 months after saline injection, but both of them improved significantly at the two time points after diprospan and diprospan+songmeile injection, respectively. Meanwhile, the latter two injection protocols led to no significant difference in pain relief and functional recovery. Similar results were obtained in patients within Group B. Furthermore, no difference of the improvement of VAS pain scores or Oswestry function scores was found between the patients within Group A and within Group B at different time points after various interventions.

CONCLUSION

Intradiscal injection of corticosteroids could be a short-term efficient alternative for discogenic low back pain patients with end plate Modic changes on MRI who were still unwilling to accept surgical operation when conservative treatment failed.

6-month results of TransDiscal Biacuplasty on patients with discogenic low back pain: preliminary findings

STUDY DESIGN

Prospective observational study.

OBJECTIVE

Our aim is to investigate the efficacy and safety of TransDiscal Biacuplasty.

SUMMARY OF BACKGROUND DATA

Chronic discogenic pain is one of the leading causes of low back pain; however, the condition is not helped by most non-invasive methods. The results of major surgical operations for these patients are unsatisfactory. Recently, attention has shifted to disk heating methods for treatment. TransDiscal Biacuplasty is one of the minimally invasive treatment methods. The method was developed as an alternative to spinal surgical practices and Intradiscal Electrothermal Therapy for treatment of patients with chronic discogenic pain.

METHODS

The candidates for this study were patients with chronic discogenic pain that did not respond to conservative treatment. The main criteria for inclusion were: the existence of axial low back pain present for 6 months; disc degeneration or internal disc disruption at a minimum of one level, and maximum of two levels, in MR imaging; and positive discography. Physical function was assessed using the Oswestry Disability Index when measuring the pain with VAS. Patient satisfaction was evaluated using a 4-grade scale. Follow-ups were made 1, 3, and 6 months after treatment.

RESULTS

15 patients were treated at one or two levels. The mean patient age was 43.1 ± 9.2 years. We found the mean symptom duration to be 40.5 ± 45.7 months. At the sixth month, 57.1% of patients reported a 50% or more reduction in pain, while 78.6% of patients reported a reduction of at least two points in their VAS values. In the final check, 78.6% of patients reported a 10-point improvement in their Oswestry Disability scores compared to the initial values. No complications were observed in any of the patients.

CONCLUSIONS

TransDiscal Biacuplasty is an effective and safe method.

Epidemiology of spine care: the back pain dilemma

In this article, the epidemiology of back pain and the use of a variety of treatments for back pain in the United States are reviewed. The dilemma faced by medical providers caring for patients with low back pain is examined in the context of epidemiologic data. Back pain is becoming increasingly common and a growing number of treatment options are being used with increasing frequency in clinical practice. However, limited evidence exists to demonstrate the effectiveness of these treatments. In addition, health-related quality of life for persons with back pain is not improving despite the availability and use of an expanding array of treatments. This dilemma poses a difficult challenge for medical providers treating individual patients who suffer from back pain.

Outcome predictors of percutaneous endoscopic lumbar discectomy and thermal annuloplasty for discogenic low back pain

PURPOSE

Endoscopic discectomy with annuloplasty is considered as a novel minimally invasive technique for treating chronic discogenic low back pain (DLBP). The purpose of this study was to evaluate the outcome predictors and to describe technical aspects for endoscopic solutions against DLBP.

MATERIALS AND METHODS

We performed a prospective study of 87 patients who underwent percutaneous endoscopic lumbar discectomy and thermal annuloplasty (PELDTA) for DLBP. The inclusion criteria were disc degenerations with annular tear confirmed by imaging studies and discography. Clinical outcomes were assessed using the visual analog scale (VAS), the Oswestry disability index (ODI), and the modified MacNab criteria. The univariate and multivariate analyses were performed to evaluate the outcome predictors.

RESULTS

The 2-year follow-up rate was 90.8% (79 of 87 patients). The VAS and ODI scores at postoperative 6 months and 2 years were significantly improved (p < 0.001). Based on the modified MacNab criteria, the global outcomes were excellent in 39 out of 79 patients (49.4%), good in 17 patients (21.5%), fair in 10 patients (12.7%), and poor in 13 patients (16.5%). Therefore, the percentage of symptomatic improvement was 83.5% and the success rate (excellent or good) was 70.9%. In the univariate and multivariate analyses, the presence of concurrent disc herniation with DLBP was the most significant predictor (OR = 3.207, 95% CI 1.02-10.06, p = 0.046).

CONCLUSIONS

PELDTA may be effective for patients with chronic DLBP in selected cases. Central disc herniation causing DLBP was the most important predictor for clinical success.

Intradiscal electrothermal therapy in the treatment of chronic low back pain: experience with 93 patients

Background:

Low back pain (LBP) has become a main cause of absenteeism and disability in industrialized societies. Chronic LBP is an important health issue in modern countries. Discogenic LBP is one of the causes of chronic low back pain. The management of chronic discogenic LBP has been limited to either conservative treatment or operative treatment. Intradiscal electrothermal therapy (IDET) is now being performed as an alternative treatment.

Methods:

Ninety-three consecutive patients undergoing IDET at 134 disc levels from October 2004 to January 2007 were prospectively evaluated. All patients had discogenic disease with chronic LBP, as determined by clinical features, physical examination and image studies, and had failed to improve with conservative treatment for at least 6 months. Follow-up period was from 1 week to 3 or more years postoperatively.

Results:

There were 50 male and 43 female patients, with a mean age of 46.07 years (range, 21-65 years). The results were classified as symptom free (100% improvement), better (≥50% improvement), slightly better (<50% improvement), unchanged and aggravated. Eighty-nine patients were followed up in the first week; of them, 77 (86.52%) patients had improvement (4, symptom free; 45, better; and 28, slightly better). The improvement rate gradually decreased to 80.90% in 1 year; and 73.91%, in 3 years.

Conclusions:

In conclusion, IDET offers a safe, minimally invasive therapy option for carefully selected patients with chronic discogenic LBP who have not responded to conservative treatment. Although IDET appears to provide intermediate-term relief of pain, further studies with long-term follow-up are necessary.

Percutaneous lumbar discectomy

Percutaneous lumbar discectomy is a proven alternative to the more invasive open discectomy used to treat patients who experience discogenic pain. Estimated to cost the United States health care system more than $20 billion a year, discogenic leg pain represents the primary cause of health care expenditure. Taken together, back pain and discogenic leg pain result in more days lost than any other combined illnesses and injuries. Annular breakdown and tears are common discogenic sources that produce pain, and are usually treated with microdiscectomy by orthopedic surgeons and neurosurgeons. Open discectomy has been considered to be the gold standard for relieving pressure on nerve roots. By decompressing the nerve root from the disc, neurologic function is usually restored and pain is relieved. Recurrent disc herniations may and typically do occur because of the annular violation that results from the surgical procedure.

Expression of semaphorin 3A and its receptors in the human intervertebral disc: potential role in regulating neural ingrowth in the degenerate intervertebral disc

Introduction

Intervertebral disc (IVD) degeneration is considered a major underlying factor in the pathogenesis of chronic low back pain. Although the healthy IVD is both avascular and aneural, during degeneration there is ingrowth of nociceptive nerve fibres and blood vessels into proximal regions of the IVD, which may contribute to the pain. The mechanisms underlying neural ingrowth are, however, not fully understood. Semaphorin 3A (sema3A) is an axonal guidance molecule with the ability to repel nerves seeking their synaptic target. This study aimed to identify whether members of the Class 3 semaphorins were expressed by chondrocyte-like cells of the IVD addressing the hypothesis that they may play a role in repelling axons surrounding the healthy disc, thus maintaining its aneural condition.

Methods

Human IVD samples were investigated using reverse transcription polymerase chain reaction (RT-PCR) to identify gene expression of sema3A, 3F and their receptors: neuropilins (1 and 2) and plexins (A1-4). Sema3A protein was also localised within sections of normal and degenerate human IVD and immunopositivity quantified. Serial sections were stained using PGP9.5 and CD31 to correlate semaphorin 3A expression with nerve and blood vessel ingrowth, respectively.

Results

Sema3A protein was expressed highly in the healthy disc, primarily localised to the outer annulus fibrosus. In degenerate samples, sema3A expression decreased significantly in this region, although cell clusters within the degenerate nucleus pulposus exhibited strong immunopositivity. mRNA for sema3A receptors was also identified in healthy and degenerate tissues. CD31 and PGP9.5 were expressed most highly in degenerate tissues correlating with low expression of sema3A.

Conclusions

This study is the first to establish the expression of semaphorins and their receptors in the human IVD with a decrease seen in the degenerate painful IVD. Sema3A may therefore, amongst other roles, act as a barrier to neuronal ingrowth within the healthy disc.

Minimally invasive spine technology and minimally invasive spine surgery: a historical review

The trend of using smaller operative corridors is seen in various surgical specialties. Neurosurgery has also recently embraced minimal access spine technique, and it has rapidly evolved over the past 2 decades. There has been a progression from needle access, small incisions with adaptation of the microscope, and automated percutaneous procedures to endoscopically and laparoscopically assisted procedures. More recently, new muscle-sparing technology has come into use with tubular access. This has now been adapted to the percutaneous placement of spinal instrumentation, including intervertebral spacers, rods, pedicle screws, facet screws, nucleus replacement devices, and artificial discs. New technologies involving hybrid procedures for the treatment of complex spine trauma are now on the horizon. Surgical corridors have been developed utilizing the interspinous space for X-STOP placement to treat lumbar stenosis in a minimally invasive fashion. The direct lateral retroperitoneal corridor has allowed for minimally invasive access to the anterior spine.

In this report the authors present a chronological, historical perspective of minimal access spine technique and minimally invasive technologies in the lumbar, thoracic, and cervical spine from 1967 through 2009. Due to a low rate of complications, minimal soft tissue trauma, and reduced blood loss, more spine procedures are being performed in this manner. Spine surgery now entails shorter hospital stays and often is carried out on an outpatient basis. With education, training, and further research, more of our traditional open surgical management will be augmented or replaced by these technologies and approaches in the future.

Percutaneous cervical disc decompression

BACKGROUND

Cervical disc nucleoplasty is a significant and clinically demonstrated innovation in percutaneous disc decompression in case of non-herniated disc protrusions or prolpase. It allows a percutaneous decompression via a 19-gauge needle under utilization of the Coblation technique and under C-arm control. Until now the patients suffering of a cervicobrachialgia in cause of a disc prolapse had only the therapeutical solution between conservative treatment and monosegmental spondylodesis or disc prosthesis of the mentioned motion segment.

METHODS

We wanted to demonstrate a new and practicable anatomical pathway for reaching the cervical disc prolapse comparable to the technique for discography of the cervical spine. The introducer needle is advanced into the disc under fluoroscopic guidance using a standard anterior-lateral approach. The controller delivers radiofrequency energy to quickly ablate tissue at temperatures between 50 degrees and 60 degrees C. The decompression will be done in ablation mode by rotating the device through 180 degrees for 5 s in the posterior, medial and ventral third of the cervical disc. After failed conservative treatment over an average time period of 3 months we treated 26 patients with a contained herniated prolapse or protrusion with radicular arm pain by percutaneous decompression under utilization of the Coblation technique with a controlled energy plasma-mediated field. A randomized control group of 30 patients was treated alone conservatively with medical and physical therapy in the same period.

RESULTS

The average preoperative VAS was 8.8. With a follow-up time of 2-years we found an average pain reduction with the visual pain score (VAS) of 2.3 who had a further check-up. The VAS was checked 24 h, 1 week, 3, 6, 12 and 24 months postoperatively. No complications with this method were seen. Comparable to the surgically treated group the conservative patients have had a VAS of 8.4. Under using conservative treatment with physical therapy, physiotherapy, analgetics and perineural injections we have had a diminution of the VAS to 5.1 after 2 years.

CONCLUSION

The percutaneous decompression of the cervical disc protrusion with the Perc DC-Spine Wand by using the Coblation mode is a quick and safe procedure. Furthermore, one may state a persistent pain relief in the follow-up time up to 2 years after the percutaneous decompression of the disc.

Intradiscal electrothermal therapy (IDET) for low back pain in worker's compensation patients: can it provide a potential answer? Long-term results

OBJECTIVE

This prospective study was conducted to evaluate improvements in pain and disability in a series of 53 consecutive worker's compensation patients with low back pain (LBP) after treatment with the intradiscal electrothermal therapy (IDET) procedure.

MATERIALS AND METHODS

All patients seen in the out-patient clinic of the Spine Institute of Louisiana for LBP of discogenic origin were screened for eligibility to receive IDET procedure. A total of 134 patients were treated using IDET for their discogenic LBP during the study period. Fifty-three patients presented to us via the worker's compensation claim program. The outcomes of these 53 patients were analyzed statistically for the current study by physical examination and self-assessment questionnaires of pain and disability at baseline and at 12-months postprocedure. Pain and disability outcomes were assessed by visual analog scale (VAS) pain score and Oswestry disability index, respectively.

RESULTS

The mean patient age was 41.83 years (range 20 to 61 y). Whites (52.8%), African-Americans (30.2%), and Hispanics (17%) formed the majority of population. Forty-nine percent were using narcotics. The first definitive end point was considered at 12 months after the procedure. Median follow-up period was 56 months (range 29 to 72 mo). A mean reduction (P<0.001) of 62.6% in the VAS score and 69.3% in the Oswestry scores was noted after IDET. The patient's initial VAS and Oswestry scores (P<0.05) significantly affected the final outcomes. About 47.2% of the patients had some degree of economic productivity and only 7 (initial 26) consumed narcotic analgesics.

CONCLUSIONS

IDET procedure can be a useful, safe, and cost-effective option in the management of carefully selected workers compensation claimants with chronic LBP of discogenic etiology.

Intradiscal electrothermal therapy (IDET) provides effective symptom relief in patients with discogenic low back pain

STUDY DESIGN

Single-arm, prospective clinical trial.

OBJECTIVE

To evaluate back pain severity, physical function, and quality of life outcomes in highly selected patients with lumbar discogenic pain treated with intradiscal electrothermal therapy (IDET).

SUMMARY OF BACKGROUND DATA

Degeneration and disruption of the intervertebral disc can be the source of severe low back pain and the associated physical dysfunction. IDET is a minimally invasive treatment option in the continuum of care between conservative nonoperative management and spinal surgery.

METHODS

Using magnetic resonance imaging, pressure-controlled discography, and postdiscogram computed tomography findings, 56 patients with lumbar discogenic pain were identified, underwent IDET treatment and followed for 20.5+/-4.4 months, on average. Outcomes included assessments of back pain severity by visual analog scale, sitting, standing, and walking tolerances, and health-related quality of life using the SF-36.

RESULTS

Mean pain severity scores (visual analog scale) improved from 6.1+/-1.8 pretreatment to 2.4+/-2.6 at final follow-up (P=0.0001). Mean tolerance times (minutes) improved from 40.9+/-40.6 to 84.5+/-54.4, 46.8+/-42.9 to 84.4+/-54.2, and 39.2+/-39.6 to 77.9+/-50.8 between baseline and final follow-up for sitting, standing, and walking, respectively (P=0.0001 for all comparisons). Seven of 8 quality of life domains showed significant (P=0.0001 for all comparisons) improvement over baseline. Forty-two patients (75%) were classified as a treatment success by virtue of a >or=2-point improvement in pain severity or a >or=10-point improvement in either the physical functioning or bodily pain domain of the SF-36.

CONCLUSIONS

The findings of this study suggest that durable clinical improvements can be realized after IDET in highly selected patients with mild disc degeneration, confirmatory imaging evidence of annular disruption, and concordant pain provocation by low pressure discography.

Acute histologic effects and thermal distribution profile of disc biacuplasty using a novel water-cooled bipolar electrode system in an in vivo porcine model

BACKGROUND

Thermal treatment of the lumbar intervertebral disc has been suggested for the treatment of chronic discogenic pain. Disc biacuplasty (D-BAC) is a novel procedure that uses two water-cooled radiofrequency electrodes in a bipolar configuration to heat a large volume of the posterior annulus fibrosus.

METHODS

Seven porcine lumbar discs were treated with D-BAC to assess acute effects on the treated tissue in a "worst-case"in vivo model. Intradiscal and peridiscal temperatures were measured during treatment and histologic analysis was used to assess for evidence of acute thermal injury.

RESULTS

Temperature monitoring at designated safety zones outside the disc demonstrated maintenance of near-physiologic conditions while temperature in the inner posterior annulus reached 65 degrees C. Histologic sections of treated discs demonstrated no evidence of thermal damage to the dorsal root ganglia or spinal nerve roots when compared with controls. Increased coarseness of the fibrillar matrix and loss of cellular detail were noted in the nucleus pulposus of treated discs.

DISCUSSION

Disc biacuplasty, in a porcine model, achieves suitable temperatures to induce thermal transition of collagen and thermoneurolysis while showing no evidence of damage to neural tissue in safety zones surrounding the disc.

Intervertebral disc: anatomy-physiology-pathophysiology-treatment

This review article describes anatomy, physiology, pathophysiology and treatment of intervertebral disc. The intervertebral discs lie between the vertebral bodies, linking them together. The components of the disc are nucleus pulposus, annulus fibrosus and cartilagenous end-plates. The blood supply to the disc is only to the cartilagenous end-plates. The nerve supply is basically through the sinovertebral nerve. Biochemically, the important constituents of the disc are collagen fibers, elastin fibers and aggrecan. As the disc ages, degeneration occurs, osmotic pressure is lost in the nucleus, dehydration occurs, and the disc loses its height. During these changes, nociceptive nuclear material tracks and leaks through the outer rim of the annulus. This is the main source of discogenic pain. While this is occurring, the degenerative disc, having lost its height, effects the structures close by, such as ligamentum flavum, facet joints, and the shape of the neural foramina. This is the main cause of spinal stenosis and radicular pain due to the disc degeneration in the aged populations. Diagnosis is done by a strict protocol and treatment options are described in this review. The rationale for new therapies are to substitute the biochemical constituents, or augment nucleus pulposus or regenerate cartilaginous end-plate or finally artificial disc implantation..

Evidence-informed management of chronic low back pain with intradiscal electrothermal therapy

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

STANDARD OPEN MICRODISCECTOMY VERSUS MINIMAL ACCESS TROCAR MICRODISCECTOMY

OBJECTIVE

Minimal access surgery as a less invasive alternative to standard macro- and microsurgical approaches is becoming increasingly popular in the management of traumatic and degenerative spine diseases. However, data is lacking if minimal access spine surgery is indeed beneficial. This prospective randomized study was conducted to compare efficiency, safety, and outcome of standard open microsurgical discectomy (SOMD) for lumbar disc herniation with microsurgical discectomy using an 11.5 mm trocar system for minimal access to the spine.

METHODS

Sixty patients were randomized to two groups of 30 patients each. Group 1 was treated by SOMD, and Group 2 was treated by minimal access microsurgical discectomy (MAMD). Perioperative parameters and pre- and postoperative clinical findings including sensory or motor deficits and pain according to the visual analog scale, Oswestry Disability Index scores, and Short Form-36 results were assessed. All patients were followed for at least 6 months postoperatively (mean, 16 mo).

RESULTS

Preoperatively, no statistically significant intergroup differences could be detected proving the comparability of both groups. Postoperatively, significant improvement of neurological symptoms and pain as measured by the visual analog scale, Oswestry Disability Index, and Short Form-36 scores could be achieved in both groups. In regard to operative time, intraoperative blood loss, and complication rate, slightly better results were observed in the MAMD group.

CONCLUSION

SOMD and MAMD allow achievement of significant improvement of pain and neurological deficits in patients with lumbar disc herniations. Differences in operative time, blood loss, and complication rates were statistically not significant in MAMD compared with SOMD, indicating that, at least in lumbar disc surgery, minimal access trocar techniques are a viable alternative to standard spinal approaches.

The Evolution and Advancement of Endoscopic Foraminal Surgery: One Surgeon's Experience Incorporating Adjunctive Techologies

Background

Endoscopic spine surgery has evolved gradually through improvements in endoscope design, instrumentation, and surgical techniques. The ability to visualize and treat painful pathology endoscopically through the foramen has opened the door for the diagnosis and treatment of degenerative conditions of the lumbar spine (from T10 to S1). Other endoscopic techniques for treating a painful disc have been focused on a posterior approach and has been compared with micro–lumbar discectomy. These procedures have not been more effective than open microdiscectomy but are less invasive, have less surgical morbidity, and allow for more rapid surgical recovery. Spinal decompression and fusion was the fallback procedure when nonsurgical treatment or discectomy failed to relieve sciatica and back pain. Foraminal endoscopic surgery, however, provides a truly minimally invasive alternative approach to the pathoanatomy of the lumbar spine because it preserves the multifidus muscle, maintains motion, and eliminates or, at worst, delays the need for fusion.

Methods

The following developments helped facilitate the evolution of a transforaminal endoscopic surgery procedure for disc herniations from a foraminal disc decompression, also known as percutaneous endoscopic lumbar discectomy, to a more complete foraminal surgical technique that can address spinal stenosis and spinal instability. This expanded capability gives foraminal endoscopic surgery distinct advantages and flexibility for certain painful degenerative conditions compared with open surgery. Advancement of the technique occurred when needle trajectory and placement was refined to better target each type of herniation with precise needle and cannula positioning directed at the herniation. New instrumentation and inclusion of a biportal technique also facilitated removal of extruded, migrated, and sequestered disc herniations. The further development of foraminoscopes with larger working channels and high speed burrs to remove bone more efficiently, along with recognition of foraminal pathoanatomy in the foramen, led to the identification and treatment of other painful degenerative conditions of the lumbar spine such as failed back surgery syndrome, recurrent disc herniations, lateral foraminal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis.

A summary of the endoscopic techniques currently used and trademarked by the author as the YESS technique include: (1) a published protocol for optimal needle and instrument placement calculated by lines drawn on the skin from the C-arm image; (2) evocative chromodiscography by the operating surgeon with nonionic radiologic contrast and indigo carmine dye to confirm concordant pain production and to stain tissue in contact with the injectate; (3) selective endoscopic discectomy, which targets the removal of loose degenerative nucleus stained differentially by indigo carmine dye; (4) thermal annuloplasty, a visualized radiofrequency thermal modulation of disc and annular defects guided by vital tissue staining; (5) endoscopic foraminoplasty, a decompression of the lateral and subarticular recess, including disc and foraminal degenerative and isthmic spondylolisthesis; (6) visually and radiologically guided exploration of the epidural space; (7) probing the hidden zone of MacNab for normal nerves (and branches of spinal nerves known as furcal nerves) versus anomalous autonomic nerves in the foramen; and (8) a uniportal and biportal technique for inside-out removal of extruded and sequestered nucleus pulposus.

Results

Endoscopic foraminal surgical procedures are not limited to disc decompression. The approaches and techniques allow access to the lumbar spine for treatment of conditions ranging from discogenic pain to failed back surgery syndrome (most commonly caused by residual or recurrent disc herniation and lateral recess stenosis). More than 3000 patients have undergone endoscopic posterolateral surgical exploration and decompression by the author since 1991. The first 80 patients reported formed the basis for expansion of techniques as new instruments and adjunctive therapy methods were added to selective endoscopic discectomy and thermal annuloplasty. New anatomic and pathoanatomic conditions were reported as they were encountered.

Conclusions

New skills will become desirable and necessary for the spine surgeon to keep up with endoscopic technology in spine care. The emphasis is on visualization of painful pathoanatomy and preservation of mobility. A new focus is on nucleus replacement, annular repair, annular reinforcement, biologics, and even transforaminal interbody fusion as the procedure of last resort. The transforaminal surgical approach to the lumbar spine can allow for minimally invasive access without negatively affecting and destabilizing the multifidus muscle.

Minimally invasive spine surgery: a historical perspective

Minimally invasive spine surgery has gained considerable momentum and increased acceptance among spine surgeons throughout the years. An understanding and awareness of the development of minimally invasive spine surgery and its role in the operative treatment of various spine conditions is imperative. This article provides a succinct historical perspective of the development of spine surgery from the more traditional, open procedures to the use of more "minimal access" or minimally invasive spine surgery procedures.

Percutaneous thermocoagulation intradiscal techniques for discogenic low back pain

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the evidence on the efficacy, effectiveness, and safety of percutaneous thermocoagulation intradiscal techniques for discogenic low back pain.

SUMMARY OF BACKGROUND DATA

The intervertebral disc is thought to be the source of pain in a relevant proportion of cases of low back pain (LBP). Two percutaneous thermocoagulation intradiscal techniques have been described to treat discogenic LBP: percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) and intradiscal electrothermal therapy (IDET).

METHODS

An electronic search was performed in MEDLINE, EMBASE, and the Cochrane Library databases up to 2005, to identify nonrandomized controlled trials and randomized controlled trials (RCTs) on those techniques. All relevant studies were methodologically assessed independently by 3 reviewers. RCTs were assessed following the criteria recommended by the Cochrane Back Review Group. A qualitative synthesis of results was performed.

RESULTS

Six studies were included with a total of 283 patients. Two open, nonrandomized trials (95 patients) showed positive results for IDET compared with rehabilitation and PIRFT. Results from 2 RCTs showed no differences between PIRFT and placebo, and between different PIRFT techniques. Two RCTs compared IDET with placebo. One suggested differences only in pain and in disability, while the best quality RCT showed no differences.

CONCLUSIONS

The available evidence does not support the efficacy or effectiveness of percutaneous thermocoagulation intradiscal techniques for the treatment of discogenic low back pain.

Treatment of multilevel degenerative disc disease with intradiscal electrothermal therapy

Intradiscal electrothermal therapy is a frequently performed procedure for the pain of internal disc disruption. It is typically performed on one to two discs; the discal treatment is followed by a long period of rest and rehabilitation. In patients with multilevel disc disease, intradiscal electrothermal therapy is either not contemplated or only one to two discs are treated at a time. This approach therefore either denies these patients the potential benefits of intradiscal electrothermal therapy or significantly prolongs the period of pain and disability. A 25-year-old female patient presented with internal disc disruption at four lumbar disc levels, diagnosed by provocative discography and post discography CT scan. All these discs were treated simultaneously by intradiscal electrothermal therapy. The patient tolerated the procedure well and responded favourably with significant and prolonged decrease in her symptoms. She reported sustained reduction in her pain and showed no clinical evidence of early neurological or infectious complications during 18 months of follow-up. This report indicates that intradiscal electrothermal therapy can be performed at multiple levels at a single sitting, compared to intradiscal electrothermal therapy performed at one to two discs at a time, this approach may obviate the need for surgery and may reduce the duration of pain and disability incurred. However, the influence of multilevel intradiscal electrothermal therapy on long-term complications or outcome is not known.

Effects of monopolar radiofrequency heating on intradiscal pressure in sheep

BACKGROUND CONTEXT

No previous study has assessed the effect of monopolar radiofrequency (RF) heating on intradiscal pressure.

PURPOSE

To determine the decrease in lumbar intradiscal pressure after monopolar RF heating.

STUDY DESIGN/SETTING

Intradiscal pressure was measured in sheep lumbar discs treated with monopolar RF heating.

METHODS

Two monopolar RF heat treatments at 90 degrees C were applied for 2 minutes each to lumbar intervertebral discs of sheep. Intradiscal pressure was measured in live sheep at 0, 7, 14, 21, and 28 days posttreatment. Pressure measurements were taken with a microtip pressure transducer. Electrodes were inserted but not activated in separate discs as a sham control. In vitro sheep spine of different age groups, loading conditions, and electrode orientations were similarly heat treated and intradiscal pressures were measured.

RESULTS

Intradiscal pressure was significantly reduced 1 week after monopolar RF heating and remained stable through the 4-week observation period. The RF electrode orientation, the age, and the type of disc loading have significant effects on the amount of initial intradiscal pressure reduction.

CONCLUSIONS

Monopolar RF heating can reduce intradiscal pressure in the lumbar spine of sheep.

Intradiscal thermal therapy using interstitial ultrasound: an in vivo investigation in ovine cervical spine

STUDY DESIGN

In vivo investigation of intradiscal ultrasound thermal therapy in ovine cervical spine model.

OBJECTIVE

To evaluate the potential of interstitial ultrasound for selective heating of intradiscal tissue in vivo.

SUMMARY OF BACKGROUND DATA

Application of heat in the spine using resistive wire and radiofrequency current heating devices is currently being used clinically for minimally invasive treatment of discogenic low back pain. Treatment temperatures are representative of those required for thermal necrosis of ingrowing nociceptor nerve fibers and disc cellularity alone, or with coagulation and restructuring of anular collagen in the high temperature case.

METHODS

Two interstitial ultrasound applicator design configurations with directional heating patterns were evaluated in vivo in ovine cervical intervertebral discs (n = 62), with up to 45-day survival periods. Two heating protocols were employed in which the temperature measured 5 mm away from the applicator was controlled to either <54 C (capable of nerve and cellular necrosis) or >70 C (for coagulation of collagen) for a 10-minute treatment period. Transient and steady state temperature maps, calculated thermal doses (t43), and histology were used to assess the thermal treatments.

RESULTS

These studies demonstrated the capability to control spatial temperature distributions within selected regions of the in vivo intervertebral disc and anular wall using interstitial ultrasound.

CONCLUSIONS

Ultrasound energy is capable of penetrating within the highly attenuating disc tissue to produce more extensive radial thermal penetration, lower maximum intradiscal temperature, and shorter treatment times than can be achieved with current clinical intradiscal heating technology. Thus, interstitial ultrasound offers potential as a more precise and faster heating modality for the clinical management of low back pain and studies of thermal effects on disc tissue in animal models.

Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain

This article was a preliminary report of prospective clinical trial of a group of patients with chronic discogenic low back pain who met the criteria for lumbar interbody fusion surgery but were treated instead with an intradiscal injection of methylene blue (MB) for the pain relief. Twenty-four patients with chronic discogenic low back pain underwent diagnostic discography with intradiscal injection of MB. The principal criteria to judge the effectiveness included alleviation of pain, assessed by visual analog scale (VAS), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. The mean follow-up period was 18.2 months (range 12-23 months). Of the 24 patients, 21 (87%) reported a disappearance or marked alleviation of low back pain, and experienced a definite improvement in physical function. A statistically significant and clinically meaningful improvement in the changes in the ODI and the VAS scores were obtained in the patients with chronic discogenic low back pain (P=0.0001) after the treatment. The study suggests that the injection of MB into the painful disc may be a very effective alternative for the surgical treatment of chronic discogenic low back pain.

Minimally invasive lumbar discectomy and foraminotomy

This article provides an overview of a minimally invasive approach for lumbar discectomy and foraminotomy. The surgical technique is described in detail, and the current literature is reviewed to assess the clinical efficacy of the procedure.