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Percutaneous nucleoplasty
1. Dr. Mohamed Mohi Eldin,
Professor Of Neurosurgery,
Cairo University
Percutaneous
Lumbar Nucleoplasty
for the Treatment of
Discogenic Pain
2. The General Recent Trend in
Spinal Surgery
Toward reduction and minimalization
The destructive effect on bony structures is
eliminated
Scar formation is greatly reduced
3. Reducing the size of the
intervertebral disc
Theoretically reduce the intradiscal pressure and
hence the pressure on the torn annulus
Creating space necessary for disc retraction.
Percutaneous Discectomy
4. Percutaneous Discectomy for
Spinal Disc Decompression ?!
By avoiding the spinal canal, avoided
complications
– infection
– Scarring (often responsible for recurrence of
pain)
Can also be repeated in the same patient
without eliminating the option of traditional
surgery.
Requiring only a short hospital stay.
5. Reducing the size of the IV disc
could be achieved by
Chemical dissolution (chemodiscolysis, 1964)
Mechanical aspiration of disc fragments
(percutaneous nucleotomy, discectomy, 1975,
1985, 2002),
Coagulation (intradiscal electrothermal
annuloplasty -IDET)
Drying (ozone)
Evaporation (laser discectomy, 1987)
Evaporation (Nucleoplasty, 2000)
8. Percutaneous
Coblation Disc Decompression
Nucleoplasty
Is said to be
– safe
– mostly painless procedure,
– with rapid recovery
– on an out patient bases
Utilizes Coblation technology
Using radiofrequency energy
– in a less damaging,
– low-temperature environment
9. Percutaneous Nucleoplasty
FDA clearance in December
1999
Introduced in 2000
Designed to vaporize the disc
nucleus
RF Generator required
Over 100,000 patients treated
world wide.
With 60 - 80% success rate in
most publications..
10. Coblation Plasma Technology
(small radiofrequency energy)
Create energised particles that have sufficient
energy to dissolve tissues inside the disc,
Allows controlled tissue removal,
11. Coblation Nucleoplasty
As the wand is going into NP,
vaporization at its end
occurs,
As the wand is retracted, the
sides of the channel will have
collagen modulation and
shrinkage of the channel size
12. Coblation
Nucleoplasty
Lower disc pressure
Efficient disc
decompression,
In an outpatient setting
However, it takes some
time for the therapy to
show its effects
14. Relative Advantages
Minimal invasion and
trauma (17 G needle)
No loss of disc height
No heat injury to the
annulus or surrounding
end plates.
19. Contra-Indications
Disc height < 50%
Severe disc degeneration
Spinal stenosis
Progressive or severe Neurological Deficit
Contained herniated disc occupying one-third
or more of spinal canal
Non-contained disc.
Evidence of Infection or Coagulopathy
Age < 18 and > 65
20. The Procedure
Procedure is done under mild endovenous
sedation and lasts 20-30 minutes
Local anaesthesia
17 Gauge needle
Ablation with the SpineWand (wire) through
the needle
23. Post Procedure Care
Procedure-related symptoms. Resolve in 7-10 days
7 days of pain medication and muscle relaxant
No lifting, bending or rotating for 1 week.
Possibly more serious problems
* Stiff neck
* Increasing pain
* Motor dysfunction
Follow up at 1 week, 1 month, 3 & 6 month, 1 year.
MRI at 6 months
26. Follow up:
- Clinical follow up at 1 week, 1 month, 3 month, 6
month and 1 y.
- Comparing VAS score and Patient Satisfaction.
- Complications rate.
- MRI at 3 and 6 months
27. Results
Total patients = 100
Age Range = 20 yrs to 66 yrs
Mean Age = 39.68 yrs
Male : Female = 63 : 35
Average Reduction Score (1 month) = 5.428
Average Reduction Score (3 months) = 5.552
Average Reduction Score (6 months) = 5.451
28. Results
Difference in
Total VAS Score => 3
Patients No.
Improved Percentage
Post procedure 98 80 81.6 %
1 month
Post procedure 87 70 80.5 %
3 months
Post procedure 82 64 78.0 %
6 months
Post procedure Improvement
(Total cases = 98)
29. Results
Complications:
– 1 Patient with discitis
– 2 Patients had increased level of pain
– 2 Patient had numbness both legs for 3 months but
pain resolved
– 30 % Patients had minor symptoms like :
Localised pain, pain at site of injection, muscle spasm
and burning sensation. For up to 2 weeks
So only 1 % significant side effect
Over all satisfaction rate is 71 %
30. 28 y M
back & left leg pain- 17m (VAS 7)
MRI showed L4/L5 central disc protrusion
Post Nucleoplasty, no pain after 3 months (VAS 0)
MRI showed significant reduction at 3 months
Pre
Post
31. 45 y F.
Acute pain (VAS 10) on top of chronic back pain – 3m
MRI showed L5/S1 left para-central protrusion.
Nucleoplasty was done for L5-S1 disc
Significant improvement (VAS 0).
Pre Post
32. 46 y M
back pain radiating to left leg - 10m (VAS 7)
MRI showed left paracentral protrusion at L5/S1 disc
Post Nucleoplasty, pain decreased to (VAS 3)
Pre Post
33. 34 y M
LBP- 13 years (VAS 10)
MRI showed L4/L5 right paracenrtal protrusion.
No improvement after 6 month (VAS 8).
However his MRI showed minimal decrease of disc bulge
Pre Post
42. Failure of The Outcome
is not failure of the idea,
but it is either
1. Failure of the selection
2. Contiuation of active degeneration
3. Part of the 30% accepted outcome
43. To Conclude:
Which patient to consider ?
Discogenic pain (axial/radicular) with no
significant neurological deficit
Failed (8-12 weeks) conservative therapy.
Contained disc (protrusion), no migration
or extrusion
Disc height > 50 %
Age < 60 y
44. Nucleoplasty is just
A new weapon in our hand
That will add to the treatment options
In a properly selected case it can
decrease the chance of open
intervention by at least 50%, if not 70%