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Mineiro J. Commentary on "Basivertevbral nerve ablation for the treatment of chronic low back pain with modic changes in a community practice setting: 6 months follow-up". NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100211. [PMID: 37124066 PMCID: PMC10131038 DOI: 10.1016/j.xnsj.2023.100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Jorge Mineiro
- Corresponding author. Head of the Orthopaedic Department and Spinal Unit, Hospital CUF Descobertas, Centro de Ortopedia e Trauimatologia, Rua M ário Botas (Parque das Na ç ões), 1998-018, Lisboa, Portugal.
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Sayed D, Naidu RK, Patel KV, Strand NH, Mehta P, Lam CM, Tieppo Francio V, Sheth S, Giuffrida A, Durkin B, Khatri N, Vodapally S, James CO, Westerhaus BD, Rupp A, Abdullah NM, Amirdelfan K, Petersen EA, Beall DP, Deer TR. Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2801-2819. [PMID: 36128549 PMCID: PMC9482788 DOI: 10.2147/jpr.s378544] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/26/2022] [Indexed: 12/05/2022] Open
Abstract
Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Ramana K Naidu
- Anesthesiology, California Orthopedics & Spine, Marin, CA, USA.,Pain Management, MarinHealth Medical Center, Marin, CA, USA
| | - Kiran V Patel
- Interventional Pain Management/ Anesthesiology, The Spine & Pain Institute of New York, New York City, NY, USA
| | - Natalie H Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | - Pankaj Mehta
- Clinical Research, Pain Specialists of Austin, Austin, TX, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Samir Sheth
- Interventional Pain Management, Sutter Health, Roseville, CA, USA
| | - Anthony Giuffrida
- Cantor Spine Center, Paley Orthopedic and Spine Institute, Fort Lauderdale, FL, USA
| | - Brian Durkin
- Pain Institute of Long Island, Port Jefferson, NY, USA
| | - Nasir Khatri
- Interventional Pain Medicine, Novant Health, Charlotte, NC, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Christopher O James
- Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, KY, USA
| | | | - Adam Rupp
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Newaj M Abdullah
- Pain Medicine and Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Kasra Amirdelfan
- Clinical Research, IPM Medical Group, Inc, Walnut Creek, CA, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Hamaguchi S, Wada S, Ogawa Y, Hashimoto K, Mimura H. A Technical Improvement for Percutaneous Puncture of the Intervertebral disc by Passing Lateral to the Superior Articular Process Using the Isocenter Puncture Method. INTERVENTIONAL RADIOLOGY 2021; 6:112-116. [PMID: 35912277 PMCID: PMC9327430 DOI: 10.22575/interventionalradiology.2021-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/13/2021] [Indexed: 11/08/2022]
Abstract
Purpose: Percutaneous intervertebral disc puncture is useful in various situations. The isocenter puncture method enables easy, accurate, and safe punctures under fluoroscopic guidance. Herein, we present a clinical application of this technique that improves upon percutaneous puncture of intervertebral discs. Material and Methods: We performed percutaneous punctures of intervertebral discs slightly lateral to the superior articular process using the isocenter puncture method in 19 cases (10 men, 9 women; mean age, 64.5 years; range, 23-87 years). We assessed the technical success rate, procedure time, and complications. Results: We achieved successful punctures in all cases, with a median puncture time of 14.5 min (mean, 18.7 ± 11.3 min; range, 8-49 min). No patients complained of complications that were permanent or required treatment. Conclusions: Improved puncture of intervertebral discs seems to be possible using the isocenter puncture method.
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Affiliation(s)
- Shingo Hamaguchi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine
| | - Shinji Wada
- Department of Radiology, St. Marianna University School of Medicine
| | - Yukihisa Ogawa
- Department of Radiology, St. Marianna University School of Medicine
| | - Kazuki Hashimoto
- Department of Radiology, St. Marianna University School of Medicine
| | - Hidefumi Mimura
- Department of Radiology, St. Marianna University School of Medicine
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Kim HS, Wu PH, Jang IT. Lumbar Degenerative Disease Part 1: Anatomy and Pathophysiology of Intervertebral Discogenic Pain and Radiofrequency Ablation of Basivertebral and Sinuvertebral Nerve Treatment for Chronic Discogenic Back Pain: A Prospective Case Series and Review of Literature. Int J Mol Sci 2020; 21:ijms21041483. [PMID: 32098249 PMCID: PMC7073116 DOI: 10.3390/ijms21041483] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 01/17/2023] Open
Abstract
Degenerative disc disease is a leading cause of chronic back pain in the aging population in the world. Sinuvertebral nerve and basivertebral nerve are postulated to be associated with the pain pathway as a result of neurotization. Our goal is to perform a prospective study using radiofrequency ablation on sinuvertebral nerve and basivertebral nerve; evaluating its short and long term effect on pain score, disability score and patients’ outcome. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain with bulging degenerative intervertebral disc or spinal stenosis underwent Uniportal Full Endoscopic Radiofrequency Ablation application through either Transforaminal or Interlaminar Endoscopic Approaches. Their preoperative characteristics are recorded and prospective data was collected for Visualized Analogue Scale, Oswestry Disability Index and MacNab Criteria for pain were evaluated. There was statistically significant Visual Analogue Scale improvement from preoperative state at post-operative 1wk, 6 months and final follow up were 4.4 ± 1.0, 5.5 ± 1.2 and 5.7 ± 1.3, respectively, p < 0.0001. Oswestery Disability Index improvement from preoperative state at 1week, 6 months and final follow up were 45.8 ± 8.7, 50.4 ± 8.2 and 52.7 ± 10.3, p < 0.0001. MacNab criteria showed excellent outcomes in 17 cases, good outcomes in 11 cases and fair outcomes in 2 cases Sinuvertebral Nerve and Basivertebral Nerve Radiofrequency Ablation is effective in improving the patients’ pain, disability status and patient outcome in our study.
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Affiliation(s)
- Hyeun Sung Kim
- Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea; (P.H.W.); (I.-T.J.)
- Correspondence: ; Tel.: +82-2-6003-9767; Fax.: +82-2-3445-9755
| | - Pang Hung Wu
- Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea; (P.H.W.); (I.-T.J.)
- National University Health Systems, Juronghealth Campus, Orthopaedic Surgery, Singapore 609606, Singapore
| | - Il-Tae Jang
- Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea; (P.H.W.); (I.-T.J.)
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MR-Guided Percutaneous Intradiscal Thermotherapy (MRgPIT): Evaluation of a New Technique for the Treatment of Degenerative Disc Disease in Cadaveric Lumbar Spine. Cardiovasc Intervent Radiol 2019; 43:505-513. [PMID: 31773189 DOI: 10.1007/s00270-019-02382-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
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.
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Gelalis I, Gkiatas I, Spiliotis A, Papadopoulos D, Pakos E, Vekris M, Korompilias A. Current Concepts in Intradiscal Percutaneous Minimally Invasive Procedures for Chronic Low Back Pain. Asian J Neurosurg 2019; 14:657-669. [PMID: 31497082 PMCID: PMC6703031 DOI: 10.4103/ajns.ajns_119_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
STUDY DESIGN A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted. OBJECTIVE The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures. MATERIALS AND METHODS English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included. RESULTS Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients. CONCLUSIONS These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.
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Affiliation(s)
- Ioannis Gelalis
- Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Ioannis Gkiatas
- Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Antonios Spiliotis
- Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece
| | | | - Emilios Pakos
- Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Marios Vekris
- Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece
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Desai MJ, Kapural L, Petersohn JD, Vallejo R, Menzies R, Creamer M, Gofeld M. Twelve-Month Follow-up of a Randomized Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain. PAIN MEDICINE 2018; 18:751-763. [PMID: 27570246 DOI: 10.1093/pm/pnw184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective This report conveys 12-month outcomes of subjects treated with intradiscal biacuplasty (IDB) and conservative medical management (CMM) for chronic low back pain of discogenic origin, and results for subjects who elected to receive IDB + CMM 6 months after CMM-alone. Methods Sixty-three subjects were originally randomized to the IDB + CMM group (N = 29) or CMM-alone (N = 34). Six months following continuous CMM-alone treatment, participants in this study group were permitted to "cross-over" to IDB + CMM (N = 25), and followed for an additional 6 months. The original IDB + CMM study subjects were followed for a total of 12 months (N = 22). Results Pain reduction at 12 months was statistically significant and clinically meaningful in the original IDB + CMM group compared to baseline. Functional and disability outcomes were also improved statistically and clinically. Fifty-five percent of the IDB + CMM patients responded to treatment with a mean VAS reduction of 2.2 points at 12 months. Furthermore, 50% and 64% of subjects reported clinically significant improvements in SF36-PF and in ODI, respectively. There was a 1.7-point reduction (improvement) on a 7-point PGIC scale, and a 0.13-point increase (improvement) in the EQ-5D Health Index. Fifty-percent of cross-over subjects responded to IDB + CMM intervention. Mean outcome scores for cross-over subjects were similar to those of the originally-treated subjects, and functional and disability endpoints were improved statistically and clinically compared to respective baseline values. Conclusions The study demonstrated long-term clinical effectiveness of IDB + CMM for treating chronic lumbar discogenic pain. Furthermore, the cross-over study subjects experienced similar improvements in pain, function, disability, and satisfaction.
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Affiliation(s)
- Mehul J Desai
- George Washington University Medical Center, Washington, District of Columbia, USA.,International Spine, Pain, and Performance Center, Washington, District of Columbia, USA
| | - Leonardo Kapural
- Center for Clinical Research, Winston-Salem, North Carolina, USA
| | | | | | - Robert Menzies
- JPS Orthopedic and Sports Medicine, Arlington, Texas, USA
| | | | - Michael Gofeld
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, Canada
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A Prospective, Randomized, Multicenter, Open-label Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain. Spine (Phila Pa 1976) 2016; 41:1065-1074. [PMID: 26689579 DOI: 10.1097/brs.0000000000001412] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study was a prospective, randomized, crossover, multicenter trial for the evaluation of comparative effectiveness of intradiscal biacuplasty (IDB) versus conventional medical management (CMM) in the treatment of lumbar discogenic pain. OBJECTIVE The objective was to demonstrate the superiority of IDB over CMM in the treatment of discogenic pain with respect to the primary outcome measure. SUMMARY OF BACKGROUND DATA Current therapeutic options for the treatment of chronic low back pain of discogenic origin are limited. CMM is often unsatisfactory with regard to the treatment of discogenic pain. IDB offers a minimally invasive treatment that has been demonstrated to be superior to placebo in the past. METHODS A total of 63 subjects with lumbar discogenic pain diagnosed via provocation discography were randomized to IDB + CMM (n = 29) or CMM-alone (n = 34). At 6 months, patients in the CMM-alone group were eligible for crossover if desired. The primary outcome measure was the change in visual analog scale (VAS) from baseline to 6 months. Secondary outcome measures included treatment "responders," defined as the proportion of subjects with a 2-point or 30% decrease in VAS scores. Other secondary measures included changes from baseline to 6 months in (1) short form (SF) 36-physical functioning, (2) Oswestry Disability Index, (3) Beck Depression Inventory, (4) Patient Global Impression of Change, (5) EQ-5D VAS, and (6) back pain-related medication usage. RESULTS In the IDB cohort, the mean VAS score reduction exceeded that in the CMM cohort (-2.4 vs. -0.56; P = 0.02), and the proportion of treatment responders was substantially greater (50% vs. 18%). Differences in secondary measures favored IDB. No differences in opioid utilization were noted between groups. CONCLUSION Superior performance of IDB with respect to all study outcomes suggests that it is a more effective treatment for discogenic pain than CMM-alone. LEVEL OF EVIDENCE 2.
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Ruiz Santiago F, Filippiadis DK, Guzmán Álvarez L, Martínez Martínez A, Castellano MM. Spinal interventions. RADIOLOGIA 2016; 58 Suppl 1:94-103. [PMID: 26778583 DOI: 10.1016/j.rx.2015.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/23/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
We review the state of the art in imaging-guided percutaneous interventional procedures used to diagnose and/or treat the diverse causes of back pain. These procedures can be used for diagnosis, treatment, or both. They are focused on the vertebral bodies, the facet joints, the intervertebral discs, and the nerve structures.
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Affiliation(s)
- F Ruiz Santiago
- Servicio de Radiodiagnóstico, Complejo Hospitalario Granada, Granada, España.
| | - D K Filippiadis
- 2nd Radiology Dpt, University General Hospital «ATTIKON», Atenas, Grecia
| | - L Guzmán Álvarez
- Servicio de Radiodiagnóstico, Complejo Hospitalario Granada, Granada, España
| | - A Martínez Martínez
- Servicio de Radiodiagnóstico, Complejo Hospitalario Granada, Granada, España
| | - M M Castellano
- Servicio de Radiodiagnóstico, Complejo Hospitalario Granada, Granada, España
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Manchikanti L, Datta S, Derby R, Helm S. Intradiscal electrothermal therapy treatment for back pain. Pain Manag 2014; 1:41-51. [PMID: 24654584 DOI: 10.2217/pmt.10.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Laxmaiah Manchikanti
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, Nashville, TN 37027, USA
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Ergün R, Şekerci Z, Bulut H, Dolgun H. Intradiscal electrothermal treatment for chronic discogenic low back pain: a prospective outcome study of 39 patients with the Oswestry disability index at 18 month follow-up. Neurol Res 2013; 30:411-6. [DOI: 10.1179/016164107x251538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Ruiz Santiago F, Castellano García MDM, Aparisi Rodríguez F. Papel de la radiología intervencionista en el diagnóstico y tratamiento de la columna vertebral dolorosa. Med Clin (Barc) 2013. [DOI: 10.1016/j.medcli.2012.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fukui S, Nitta K, Iwashita N, Tomie H, Nosaka S, Rohof O. Results of intradiscal pulsed radiofrequency for lumbar discogenic pain: comparison with intradiscal electrothermal therapy. Korean J Pain 2012; 25:155-60. [PMID: 22787545 PMCID: PMC3389319 DOI: 10.3344/kjp.2012.25.3.155] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 05/23/2012] [Accepted: 05/29/2012] [Indexed: 01/20/2023] Open
Abstract
Background We have developed an intradiscal pulsed radiofrequency (Disc PRF) technique, using Diskit II® needles (NeuroTherm, Wilmington, MA, USA), as a minimally invasive treatment option for chronic discogenic low back pain (LBP). The purpose of this study was to compare the representative outcomes of Disc PRF and Intradiscal Electrothermal Therapy (IDET) in terms of pain relief and reduction of disability. Methods Thirty-one patients with chronic discogenic LBP who underwent either Disc PRF (n = 15) or IDET (n = 16) were enrolled in the study. A Diskit II® needle (15-cm length, 20-gauge needle with a 20-mm active tip) was placed centrally in the disc. PRF was applied for 15 min at a setting of 5 × 50 ms/s and 60 V. The pain intensity score on a 0-10 numeric rating scale (NRS) and the Roland-Morris Disability Questionnaire (RMDQ) were assessed pretreatment and at 1, 3, and 6 months post-treatment. Results The mean NRS was significantly improved from 7.2 ± 0.6 pretreatment to 2.5 ± 0.9 in the Disc PRF group, and from 7.5 ± 1.0 to 1.7 ± 1.5 in the IDET group, at the 6-month follow-up. The mean RMDQ also showed significant improvement in both the Disc PRF group and the IDET group at the 6-month follow-up. There were no significant differences in the pretreatment NRS and RMDQ scores between the groups. Conclusions Disc PRF appears to be an alternative to IDET as a safe, minimally invasive treatment option for patients with chronic discogenic LBP.
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Affiliation(s)
- Sei Fukui
- Pain Management Clinic, Department of Anesthesiology, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
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Fukui S, Rohof O. Results of pulsed radiofrequency technique with two laterally placed electrodes in the annulus in patients with chronic lumbar discogenic pain. J Anesth 2012; 26:606-9. [PMID: 22476553 DOI: 10.1007/s00540-012-1385-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 03/20/2012] [Indexed: 11/25/2022]
Abstract
Discogenic pain is an important cause of low back pain (LBP). We have developed a pulsed radiofrequency (P-RF) technique, using two electrodes placed bilaterally in the annulus, for applying radiofrequency current in the disc (bi-annular P-RF disc method). The purpose of this study was to investigate the effect of the bi-annular P-RF disc method, using Diskit needles (Neurotherm, Middleton, MA, USA) in patients with discogenic LBP. The subjects were 15 patients with a mean age of 37.3 ± 8.63 years with chronic discogenic lower back pain that was not responsive to aggressive nonoperative care. Two Diskit II needles (15-cm length, 20G needles with a 20-mm active tip) were placed bilaterally in the annulus in the disc. Pulsed radiofrequency was applied for 12 min at a setting of 5 × 50 ms/s and 60 V. The pain intensity scores on a 0-10 numeric rating scale (NRS) and the Roland-Morris Disability Questionnaire (RMDQ) were measured pretreatment, and at 1 week and 1, 3, and 6 months post-treatment. The mean pain severity score (NRS) improved from 7.27 ± 0.58 pretreatment to 2.5 ± 0.94 at the 6-month follow-up (p < 0.01). The RMDQ showed significant (p < 0.01) improvement, from 10.70 ± 2.35 pretreatment to 2.10 ± 1.85 at the 6-month follow up (p < 0.01). The bi-annular P-RF disc method with consecutive P-RF 5/5/60 V, 12-min (with Diskit needle), appears to be a safe, minimally invasive treatment option for patients with chronic discogenic LBP.
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Affiliation(s)
- Sei Fukui
- Pain Management Clinic, Shiga University of Medical Science Hospital, Tukinowa, Seta, Otsu, Shiga, 520-2192, Japan.
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15
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Percutaneous intradiscal treatments for discogenic pain. ACTA ACUST UNITED AC 2012; 50:25-8. [DOI: 10.1016/j.aat.2012.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 01/03/2012] [Accepted: 01/06/2012] [Indexed: 11/18/2022]
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Ko Y, Kim YH. Interventional therapy for chronic low back pain. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2012. [DOI: 10.5124/jkma.2012.55.6.562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University School of Medicine, Deajeon, Korea
| | - Yoon Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University School of Medicine, Deajeon, Korea
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Rohof O. Intradiscal pulsed radiofrequency application following provocative discography for the management of degenerative disc disease and concordant pain: a pilot study. Pain Pract 2011; 12:342-9. [PMID: 22008239 DOI: 10.1111/j.1533-2500.2011.00512.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The development of diagnostic criteria and the use of provocative discography allow identifying the degenerative disc as causative structure for chronic low-back pain. Unfortunately, none of the available interventional treatment options have been demonstrated to be effective over a prolonged period of time for a considerable number of patients. Pathophysiological studies indicate sprouting of sensory nerves and inflammatory processes as underlying pain mechanisms. Pulsed radiofrequency (PRF) treatment in small and larger joints was described to reduce pain and improve healing by stimulating the immunology. Earlier findings of PRF applied in the disc annulus were promising. It is assumed that PRF applied in the nucleus would change the conductivity of nerve endings and provide a clinically relevant pain reduction. The application of the electric field of PRF in the disc may also activate the immune system, thus reducing the inflammation process of chronic pain. Pulsed radiofrequency in the nucleus was studied in 76 patients with discogenic pain confirmed by magnetic resonance imaging and provocative discography. At 3-month follow-up, 38% of the patients had > 50% pain reduction, at 12 month the effect is maintained in 29%. In patients with unsatisfactory pain relief 3 months after the intervention, secondary pain sources may have been revealed. The latter were treated accordingly. Of all patients, 56% had > 50% pain reduction 1 year after first treatment. Our findings suggest that PRF in the nucleus may be considered for patients with proven discogenic pain. A randomized controlled trial to confirm our findings is justified.▪
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Affiliation(s)
- Olav Rohof
- Pain Clinic, Orbis Medical Center, Sittard Geleen, The Netherlands.
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Iwatsuki K, Yoshimine T, Umegaki M, Yoshimura K, Ohnishi YI, Ishihara M, Moriwaki T. Percutaneous diode laser irradiation for lumbar discogenic pain: a clinical study. Photomed Laser Surg 2011; 29:459-63. [PMID: 21323427 DOI: 10.1089/pho.2010.2861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The present study evaluated the efficiency of laser irradiation for treating discogenic low back pain. Discogenic low back pain is believed to result from the degeneration and disruption of outer fibers of the intervertebral disc annulus, leading to a cycle of persistent inflammation, damage to the disc matrix, and sensitization of developed annular nociceptors. We selected 11 patients as subjects on the basis of clinical findings and the results of provocative disc blockade. The patients underwent percutaneous irradiation of affected lumbar discs with a diode laser. The mean total irradiation energy per disc was 740 ± 2.51 J, with a range of 610 to 960 J. The patients' responses were assessed with the Oswestry Disability Index (ODI) and a visual analogue scale (VAS) to determine the average level of pain. The patients' mean ODI scores at 1 day, 3 months, 6 months, 12 months, 18 months, and 24 months after laser irradiation were 18.63 ± 11.22, 13.6 ± 4.53, 12.5 ± 5.5, 11.8 ± 5.25, 10.5 ± 2.27, and 10.5 ± 2.27, respectively, versus a mean pre-treatment ODI score of 50.27 ± 9.35. Their mean VAS scores at the same post-treatment intervals were 3.09 ± 2.36, 2.4 ± 0.97, 2.7 ± 1.16, 2.1 ± 0.74, 2.1 ± 0.81, and 2.1 ± 0.88, respectively, versus a mean pre-treatment VAS score of 7.64 ± 1.21. The post- versus pre-treatment scores for both the ODI and VAS indicated a statistically significant clinical benefit across the full 24-month follow-up period after laser irradiation. The efficacy of laser irradiation in treating such pain may come from a thermal effect and reductions of intradiscal pressure, of the concentrations of irritant substances, and of the numbers of nociceptors in the affected region.
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Affiliation(s)
- Koichi Iwatsuki
- Department of Neurosurgery, Osaka University Medical School, Japan.
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Treatment of discogenic low back pain with Intradiscal Electrothermal Therapy (IDET): 24 months follow-up in 50 consecutive patients. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 108:103-5. [PMID: 21107944 DOI: 10.1007/978-3-211-99370-5_15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Degeneration of the intervertebral disc can be the source of severe low back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption nonresponsive to conservative medical care. METHODS Using MRI and discographic findings, 50 patients with lumbar discogenic pain were identified, underwent IDET treatment and were followed for 24 months. Outcomes included assessments of back pain severity by an 11-point numeric scale and back function by the Oswestry disability index (ODI). FINDINGS There was an average 68 and 66% improvement in pain and ODI, respectively, between pre-treatment and 24 months (p < 0.0001 for both comparisons). The global clinical success rate was 78% (39 of 50). Clinical success was associated with discographic concordance (p < 0.0001), HIZ (p = 0.003), Pfirrmann grade (p = 0.0002), and percent annulus coverage (p < 0.0001). 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.
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Abstract
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.
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Affiliation(s)
- Janna Friedly
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Kallewaard JW, Terheggen MAMB, Groen GJ, Sluijter ME, Derby R, Kapural L, Mekhail N, Van Kleef M. 15. Discogenic Low Back Pain. Pain Pract 2010; 10:560-79. [DOI: 10.1111/j.1533-2500.2010.00408.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Tsou HK, Chao SC, Kao TH, Yiin JJ, Hsu HC, Shen CC, Chen HT. Intradiscal electrothermal therapy in the treatment of chronic low back pain: experience with 93 patients. Surg Neurol Int 2010; 1:37. [PMID: 20847918 PMCID: PMC2940097 DOI: 10.4103/2152-7806.67107] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Accepted: 06/25/2010] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Hsi-Kai Tsou
- Department of Neurosurgery, Taichung Veterans General Hospital, 160 Sec3 Chung-Kang Road, Taichung - 407 05, Taiwan, R.O.C.
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Kelekis AD, Filippiadis DK, Martin JB, Brountzos E. Standards of practice: quality assurance guidelines for percutaneous treatments of intervertebral discs. Cardiovasc Intervent Radiol 2010; 33:909-13. [PMID: 20676639 DOI: 10.1007/s00270-010-9952-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 04/01/2010] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Alexis D Kelekis
- 2nd Radiology Department, Attikon University Hospital, Haidari, Athens, Greece.
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Assietti R, Morosi M, Block JE. Intradiscal electrothermal therapy for symptomatic internal disc disruption: 24-month results and predictors of clinical success. J Neurosurg Spine 2010; 12:320-6. [DOI: 10.3171/2009.9.spine09301] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Degeneration of the intervertebral disc can be the source of severe low-back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption unresponsive to conservative medical care. This study was undertaken in the neurosurgical setting to evaluate 24-month pain and functional outcomes and predictors of clinical success in patients with discogenic back pain treated with IDET.
Methods
Using MR imaging and discography findings, 50 patients with lumbar discogenic pain were identified, underwent IDET treatment, and were followed up for 24 months. Outcomes included assessments of back pain severity based on an 11-point numeric scale and back function based on the Oswestry Disability Index. The Prolo scale was applied to determine economic and functional status at 24 months.
Results
There was an average 68 and 66% improvement in back pain and function, respectively, between pretreatment and 24 months after treatment (p < 0.0001 for both comparisons). A maximum score of 5 on the Prolo scale for economic and functional status was achieved in 63 and 22% of patients, respectively. The global clinical success rate was 78% (39 of 50 patients) based on no reoperations at the affected level due to persistent symptoms, with a ≥ 2-point improvement in pain severity and a ≥ 15-point improvement in back function. Predictors of 24-month clinical success included discographic concordance (p < 0.0001), a high-intensity zone on MR imaging (p = 0.0003), low Pfirrmann grade (p = 0.0002), and more extensive anulus coverage (p < 0.0001). There were no procedure-related adverse events.
Conclusions
The findings of this study suggest that durable clinical improvements can be realized after IDET in highly select surgical candidates with mild disc degeneration, confirmatory imaging evidence of anular disruption, and highly concordant pain provocation on low-pressure discography.
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Affiliation(s)
- Roberto Assietti
- 1Department of Neurosurgery, Ospedale Fatebenefratelli E Oftalmico, Milano, Italy; and
| | - Mario Morosi
- 1Department of Neurosurgery, Ospedale Fatebenefratelli E Oftalmico, Milano, Italy; and
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Chou R. Same trials, different conclusions: sorting out discrepancies between reviews on interventional procedures of the spine. Spine J 2009; 9:679-89. [PMID: 19540814 DOI: 10.1016/j.spinee.2009.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 04/18/2009] [Accepted: 05/08/2009] [Indexed: 02/03/2023]
Affiliation(s)
- Roger Chou
- Department of Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34:1078-93. [PMID: 19363456 DOI: 10.1097/brs.0b013e3181a103b1] [Citation(s) in RCA: 234] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain. SUMMARY OF BACKGROUND DATA Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy. METHODS Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies. CONCLUSION Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
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Lee SH, Kang HS. Percutaneous endoscopic laser annuloplasty for discogenic low back pain. World Neurosurg 2009; 73:198-206; discussion e33. [PMID: 20860958 DOI: 10.1016/j.surneu.2009.01.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 01/24/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Laser-assisted spinal endoscopy (LASE) kit has been used for percutaneous intradiscal decompression to evaporate and shrink the posterior and central nucleus for improvement of leg and radicular pain due to contained disc herniation. Percutaneous endoscopic laser annuloplasty (PELA), a new minimally invasive technique, uses LASE to directly coagulate the inflamed disc granulation tissue associated with annular tears. The small diameter of the endoscope including Ho:YAG laser, irrigation, and light, plus the extreme posterolateral approach into the posterior annulus, enables one to minimize damage to normal nuclear tissue. The authors sought to demonstrate the safety and efficacy of PELA for controlling discogenic low back pain (DLBP) due to abnormal disc tissues, new vessels, and nerves in the central torn posterior annulus. METHODS Clinical outcomes of PELA were investigated in patients having DLBP with an annulus-torn degenerative disc or contained disc herniation. Thirty patients treated at a single level and achieving a mean follow-up of 9.7 months were analyzed. Outcomes were assessed using the visual analog scale (VAS) for back pain, the Korean Oswestry Disability Index (KODI), and the modified Macnab's criteria. RESULTS The mean back pain VAS score improved from 8.0 to 2.4, and the mean KODI score improved from 79.0 to 22.4 (P < .001). Results by the modified Macnab's criteria also showed a good outcome, with a success rate of 90.0%. There were no serious complications observed during follow-up. CONCLUSIONS Percutaneous endoscopic laser annuloplasty using the Ho:YAG laser provides favorable outcomes for carefully selected groups of patients with DLBP.
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Affiliation(s)
- Sang-Ho Lee
- Department of Neurosurgery, Seoul Wooridul Hospital, Seoul 157-822, Korea.
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Guarnieri G, Vassallo P, Pezzullo MG, Laghi F, Zeccolini F, Ambrosanio G, Galasso R, Muto M, Izzo R. A comparison of minimally invasive techniques in percutaneous treatment of lumbar herniated discs. A review. Neuroradiol J 2009; 22:108-21. [PMID: 24206960 DOI: 10.1177/197140090902200116] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 02/22/2009] [Indexed: 11/16/2022] Open
Abstract
Low back pain is the commonest spine disease causing absence from work in developed countries. Low back pain with classical irradiation along the course of the nerve root affected is more frequently due to disc disease. In 60-80% of patients with herniated disc, radicular symptoms disappear with conservative treatment after about six weeks, the remainder are treated surgically with a 2-6% of incidence of true recurrence of herniation post-intervention and with failed back surgery syndrome in 15% of cases. Recently minimally invasive techniques have developed as "alternative" treatments to surgical intervention. This review aimed to assess the pathogenesis of low back pain caused by lumbar disc hernia as a basis for action of minimally invasive techniques; to illustrate the techniques already used or currently in use, to compare them in technical guidance, indications and complications, exposing for each of them the inclusion/exclusion criteria in enrolling patients and the imaging guide technique of choice. Minimally invasive techniques can be a valuable alternative to traditional surgery with low cost, low risk of complications, easy feasibility, and in the event of failure they do not exclude subsequent surgery.
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Affiliation(s)
- G Guarnieri
- Neuroradiology Service, A.O.R.N. A. Cardarelli Hospital; Naples, Italy -
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Heran MKS, Smith AD, Legiehn GM. Spinal injection procedures: a review of concepts, controversies, and complications. Radiol Clin North Am 2008; 46:487-514, v-vi. [PMID: 18707959 DOI: 10.1016/j.rcl.2008.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.
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Affiliation(s)
- Manraj K S Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, Canada.
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Carreon LY, Glassman SD, Howard J. Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and MOS Short Form-36 outcomes. Spine J 2008; 8:747-55. [PMID: 18037354 DOI: 10.1016/j.spinee.2007.06.013] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 06/25/2007] [Accepted: 06/25/2007] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although numerous studies have been published, controversy still exists regarding fusion and nonsurgical treatment for symptomatic degenerative lumbar spine conditions. Definite conclusions are difficult to draw because of differences in patient inclusion criteria, fusion technique, nonoperative treatment regimen, and clinical outcome measures used to determine success. PURPOSE The objective of this study was to evaluate lumbar fusion and nonsurgical interventions for various degenerative spine disorders using the Oswestry Disability Index (ODI) as a primary outcome measure in a systematic review. A secondary objective was to determine whether there is a difference in clinical outcomes based on the specific diagnosis. STUDY DESIGN/SETTING Systematic review. PATIENT SAMPLE Patients with low back pain of at least 12 weeks duration and older than 18 years, with prospectively collected ODI scores and at least a 12-month follow-up. OUTCOME MEASURES ODI and Short Form-36 (SF-36). METHODS A MEDLINE, HealthSTAR, CINAHL, and Cochrane database search was done using the search strategy recommended by the Cochrane Back Review Group. Proceedings from annual meetings of various spine societies and reference lists from review articles and retrieved articles were evaluated for possible inclusion. Criteria for inclusion were prospective randomized clinical trials in patients with low back pain of at least 12 weeks duration and older than 18 years; with prospectively collected ODI scores and at least a 12-month follow-up. The methodological quality of the studies was assessed using the van Tulder criteria. Data extracted from each study included demographics, study design, diagnosis, baseline and change in ODI, and baseline and change in SF-36 Physical Composite Score (PCS). The data were pooled and analyzed based on the primary reported inclusion diagnosis: degenerative disc disease (DDD), chronic low back pain (CLBP), and spondylolisthesis; and treatment: fusion (unspecified, posterior, anterior, combined) and nonsurgical. RESULTS Twenty-five studies met the inclusion criteria. The distribution of sex and smokers was similar across diagnoses and treatments. Patients with spondylolisthesis were older than patients with DDD and CLBP. Patients with spondylolisthesis had the greatest ODI improvement followed by patients with DDD and CLBP. The three fusion types produced similar amounts of improvement in ODI. Nonsurgical patients did not improve as much but had a lower baseline ODI. Improvements in the SF-36 PCS were fairly consistent across diagnostic groups and treatment types. CONCLUSIONS Substantial improvement can be expected in patients treated with fusion, regardless of technique, when an established indication such as spondylolisthesis or DDD exists. CLBP patients are less disabled and experience less improvement.
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Intradiscal electrothermal therapy (IDET) provides effective symptom relief in patients with discogenic low back pain. ACTA ACUST UNITED AC 2008; 21:55-62. [PMID: 18418138 DOI: 10.1097/bsd.0b013e31812f4f29] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Rathmell JP, Saal JS, Saal J. Discography, IDET, Percutaneous Discectomy, and Nucleoplasty: Complications and Their Prevention. PAIN MEDICINE 2008. [DOI: 10.1111/j.1526-4637.2008.00442.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
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..
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Affiliation(s)
- P Prithvi Raj
- Department of Anesthesiology and Pain Management, Texas Tech University, Lubbock, Texas, USA.
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Derby R, Baker RM, Lee CH, Anderson PA. Evidence-informed management of chronic low back pain with intradiscal electrothermal therapy. Spine J 2008; 8:80-95. [PMID: 18164457 DOI: 10.1016/j.spinee.2007.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Accepted: 10/13/2007] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Richard Derby
- Spinal Diagnostics & Treatments Center, 901 Campus Drive, Suite 312, Daly City, CA 94015-4900, USA.
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Re: Urrútia G, Kovacs F, Nishishinya MB, et al. Percutaneous thermocoagulation intradiscal techniques for discogenic low back pain. Spine 2007;32:1146-54. Spine (Phila Pa 1976) 2007; 32:2927-8; author reply 2928-9. [PMID: 18246022 DOI: 10.1097/brs.0b013e31815b9e7d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Malik K. Treatment of multilevel degenerative disc disease with intradiscal electrothermal therapy. Anaesth Intensive Care 2007; 35:289-93. [PMID: 17444324 DOI: 10.1177/0310057x0703500223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- K Malik
- Department of Anesthesiology, Illinois Masonic Medical Center, Chicago, Illinois, USA
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